Remote: Appeals Specialist II – FEP Appeals – Entry Level WAH

Telecommuter

Time type – Full time

Job requisition id – R26406
Join Our Team: Do Meaningful Work and Improve People’s Lives
Our purpose, to improve customers’ lives by making healthcare work better, is far from ordinary. And so are our employees. Working at Premera means you have the opportunity to drive real change by transforming healthcare.

To better serve our customers, we’re creating a culture that promotes employee growth, collaborative innovation, and inspired leadership.

Forbes ranked Premera among America’s 2023 Best Midsize Employers because we are committed to creating an environment where employees can do their best work and where best-in-class talent comes, stays, and thrives!

The Appeals Specialist II researches and responds to inquiries, complaints and grievances received from numerous external sources. These sources may include attorneys and other legal entities, members, providers, state and federal regulatory agencies, and various other external parties. To respond to internal referred issues either independently or in collaboration with others. To support the member service/customer service teams and other partner areas in resolving issues dealing with various inquiries and complaints.

What you’ll do:

Research, coordinate and resolve issues related to claims processing, eligibility, contracts, call history, benefits quotes, appeal decisions and decisions to reduce, modify or deny services to members. May determine proper solutions to issues raised by legal entities, members, and state and federal regulatory agencies.
Document inquiries and formulate solutions to problems and issues.
Review databases and files used to maintain accuracy, inputting corrections as necessary. Recognize and identify trends and presents findings to management.

Approve/deny contractual disputes within limits of position authority.
Collaborate and communicate verbally and in writing via phone, email, letter, etc. with external and internal sources regarding a variety of complaint and appeal issues which may include claims eligibility, contract issues, and/or the preparation and organization of member appeals.
Provide accurate and timely maintenance of system and case file records for use in reporting appropriate department data.
Represent the appeals area in meetings requiring team expertise and participation.
Identify and communicate necessary contract revisions/clarifications based on defects identified. Interpret member benefit booklet contract language and/or provider contract language and apply it to the appeal issue.

Meet or exceed departmental goals of production, accuracy, and timeliness.
Work collaboratively with internal and external (including vendors) parties to thoroughly research and respond to all cases.
As needed, assist with reviewing, entering, and appropriately responding to new inquiries and requests. Review and research incoming mail and faxes to determine the correct recipient and triage expedited appeals requests.
Serve as back up to other team members as needed.
Other duties as assigned.

What you’ll bring:

A High School Diploma or GED and 1 year of claims processing and/or customer service experience (Required)
Experience in complaints or appeals, knowledge of Premera platforms, and/or an understanding of BlueCard Programs would be preferred.
Proven research and analytical skills.
Communicates verbally and in writing with external and internal sources regarding claims eligibility and contract issues.
Proficiency with basic mathematical concepts.
Strong verbal and written communication skills.
Excellent customer relations skills, as well as the ability to communicate, and remain objective throughout difficult communications.
Ability to work independently and as a member of a team on concurrent projects with all levels of Premera employees.

What we offer
Medical, vision and dental coverage
Life and disability insurance
Retirement programs (401K employer match and pension plan)
Wellness incentives, onsite services, a discount program and more
Tuition assistance for undergraduate and graduate degrees
Generous Paid Time Off to reenergize
Free parking

Equal employment opportunity/affirmative action:
Premera is an equal opportunity/affirmative action employer. Premera seeks to attract and retain the most qualified individuals without regard to race, color, religion, sex, national origin, age, disability, marital status, veteran status, gender or gender identity, sexual orientation, genetic information or any other protected characteristic under applicable law.

If you need an accommodation to apply online for positions at Premera, please contact Premera Human Resources via email at careers@premera.com or via phone at 425-918-4785.

The pay for this role will vary based on a range of factors including, but not limited to, a candidate’s geographic location, market conditions, and specific skills and experience.

National Salary Range:

$41,600.00 – $62,400.00

National Plus Salary Range:

$47,000.00 – $70,500.00

*National Plus salary range is used in higher cost of labor markets including Western Washington and Alaska.