UM Appeals Analyst - MAC

About the Role This position supports the Health Services and Utilization Management functions and acts as a liaison between Members, Physicians, Delegates, Operational Business members, and Member Service Coordinators. The incumbent prepares and presents appeals cases and participates in the Horizon Member Appeals Committee (MAC) & Expedited Subcommittee hearings. Incumbent mentors more junior staff by responding to questions and sharing expertise.

Incumbent adheres to all regulated processes and timeframes in accordance with the 1st, 2nd level and Special Process UM Appeal workflows. What You’ll Do Performs review of service requests for completeness of information, collection and transfer of non-clinical data, and acquisition of structured clinical data from physicians/patients. Handles initial screening for UM Appeals requests from physicians/members/facilities/authorized representatives via incoming calls or correspondence based on workflows.

Manages correspondence of toll-free UM Appeal hotline and UM Appeal fax server, including speaking with various customers, education, triaging calls, and disseminating information during business hours. Also handles calls to the appellant, education, triaging incoming faxes, and assigning appeals. Interacts with and supports Medical Directors by scheduling and arranging peer-to-peer discussions with physicians and our Horizon Medical Directors, preparing, documenting and routing cases in appropriate system for clinical review.

Prepares, presents, and schedules cases for the Member Appeals Committee (MAC) and Expedited Subcommittees, providing comprehensive explanation of previous denials, scope of coverage, applied criteria, and case handling. Addresses questions from the appellant or committee and administratively supports completion of the appeals process. Partners with all parties that handled the case to facilitate fact gathering and gain thorough understanding of the determination and appropriate benefits.

Conducts root cause analysis to avoid future appeal occurrences and works with supervisor to develop and deliver refresher training to business teams on proper appeal referral, handling, and MAC case preparation. Assists in the development of junior staff through mentoring, coaching, and assistance in proper handling of appeal cases. Acts as a mentor by responding to questions and sharing expertise.

Assists with running and validating reports for the team. Performs other relevant tasks as assigned by Management. What You Bring High School Diploma/GED required.

Requires minimum of 5 years healthcare industry or operations experience. Requires minimum 3 years direct customer service experience, preferably in a medical support related position. Prefer experience with prior appeals handling and correspondence.

This Position Is Required to work a specified number of weekends and holidays to meet Regulatory and Accrediting body standards. Requirements may vary based on department’s business needs. Knowledge Requires knowledge of medical terminology.

Prefer knowledge of UCSW, Medical Policy guidelines, and Care Radius. Prefer knowledge of contracts, enrollment, billing, & claims coding/processing. Prefer knowledge of Managed Care principles.

Skills and Abilities Requires strong oral and written communication skills. Requires ability to make sound decisions under the direction of the supervisor. Prefer the ability to analyze and resolve problems with minimal supervision.

Must be proficient in the use of personal computers and supporting software in a Windows based environment, including MS Office products (Word, Excel, PowerPoint and Microsoft Outlook). Benefits Salary Range: $63,000 - $84,420 This compensation range is specific to the job level and takes into account the wide range of factors that are considered in making compensation decisions, including but not limited to: education, experience, licensure, certifications, geographic location, and internal equity. Comprehensive health benefits (Medical/Dental/Vision) Retirement Plans Generous PTO Incentive Plans Wellness Programs Paid Volunteer Time Off Tuition Reimbursement Disclaimer: Horizon Blue Cross Blue Shield of New Jersey employees must live in New Jersey, New York, Pennsylvania, Connecticut or Delaware.

This job summary has been designed to indicate the general nature and level of work performed by colleagues within this classification. It is not designed to contain or be interpreted as a comprehensive inventory of all duties, responsibilities, and qualifications required of colleagues assigned to this job. Horizon Blue Cross Blue Shield of New Jersey is an Equal Opportunity/Affirmative Action employer.

All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran status or status as an individual with a disability and any other protected class as required by federal, state or local law. Horizon will consider reasonable accommodation requests as part of the recruiting and hiring process. #J-18808-Ljbffr