Posted in Other 30+ days ago.
Location: Durham, North Carolina
What You'll Do
* Research and investigate all aspects of the member and provider appeals and grievances, NCDOI, Congressional and/or Department of Justice complaints to ensure compliance with medical necessity criteria, Corporate Medical Policy (CMP), member and provider contract provisions, State and/or Federal requirements, BCBSA guidelines and/or other mandated requirements (e.g. Thomas Love Settlement), NCQA Standards, Current Procedural Terminology (CPT), ICD-9, and Healthcare Common Procedure Coding System guidelines (HCPCS), as applicable.
* Investigate member and provider appeals and grievances and NCDOI, Congressional and/or Department of Justice complaints for all lines of business, excluding FEP, by reviewing applicable resources (i.e. CMP, CMS guidelines, CPT coding guidelines, Reconsideration/Appeal Manual, contract provisions, legislation, BCBSNC management, and/or NCQA requirements.
* Identify, collect, and analyze appropriate documentation from multiple internal systems including claims, customer contract management, benefit booklets, UM systems, coding claim edits, etc. and external sources including pharmaceutical companies, attorneys, providers, Medicare, PBMs, etc.
* Serves as a SME (subject matter expert) on benefits and claims related issues.
* Provides support and assistance to Appeals Analysts on investigative techniques and proper corrective actions required to resolve appeals and grievances.
* Perform extensive informational research as necessary.
* Coordinate and draft responses to NCDOI, Congressional and/or DOJ complaints with all Enterprise Departments to ensure timely and accurate resolution.
* Consult and confer with medical directors and other clinical staff to ensure the appropriate decision has been made and the approved outcomes are implemented.
* Review, analyze and make determinations on provider requests for increased payments related to coding and/or bundling issues.
* Communicate findings of analysis and documentation to appropriate committee, benefit administrators and BCBSNC leadership, as necessary.
* Initiate claim adjustments on individual cases when necessary and follow and track until completion.
* Provide written documentation of case determinations to appellants and/or all involved parties (including but not limited to physicians, attorneys, senators/legislators, employer groups, etc.) in a timely manner as required by regulatory mandates and legislation.
* Identify trends and high-risk issues to mitigate risk of potential legal actions and/or NCOI focused audits and penalties. Communicate findings to the Legal department, Corporate Communications, Special Investigations, and Healthcare Senior Management. Make recommendations to address future exposure.
* Audit appeal and grievance files as required by Federal and/or State regulatory agencies and provide feedback, education and training to individual employees to ensure compliance with mandates.
* Audit and oversight of entities where delegation of member and provider appeals exists.
* Identify and take corrective action on appeals or grievances that result from noncompliance of contract provisions, appeal or grievance guidelines, provider contract violations and/or medical policies.
* Stays current with press releases, emails, and other forms of communications relaying initiatives, contracting issues, as well as Plan wide concerns.
* Identify and create action plans to educate internal departments on benefit misinterpretation and/or claim payment system errors.
* Answer member/provider questions via incoming telephone calls in a professional quality driven manner.
* May handle complaints/grievances as defined by the federal government.
What You'll Bring (Hiring Requirements)
Bachelor's degree and two years experience working in appeals and grievances, claims, and customer service; or combination of equivalent background
If no degree, four years experience working in appeals and grievances, claims, and customer service; or combination of equivalent background
Experience and/or aptitude to assist other staff members with complex and difficult assignments in a courteous and respectful manner
Proficiency in Microsoft Office
Nice to Have
Federal Employee Program (FEP) line of business experience