Appeals Case Owner

All about us

You likely know us as an insurance company, but that’s just a portion of what we do. Hundreds of thousands of North Dakotans trust us to provide them with personalized service and unmatched access to care. It’s a mission we take seriously.

We also work with entities throughout the state to challenge the cost and complexity of health care in North Dakota. This uncompromising goal requires caring, innovative people who are ready and willing to help create a new level of health and well-being in North Dakota and beyond.

Work environment

This opportunity is eligible for a remote, hybrid, or in-office work arrangement. We empower our employees to find a work style that is best for them. Learn more at Life at Blue | BCBSND.

This position is eligible for internal and external applications.

Pay Information

• Pay Level: 017
• FLSA Category: Non-Exempt - Hourly
• Individual pay will be based on skills, experience, qualifications, location, internal equity, and other relevant factors.
• Opportunities for continued salary growth through a performance-based merit program.

A day in the life

The Appeals Case Owner is responsible for the management of reviewing, researching, and resolving grievances, appeals, complaints and disagreements by members and providers. This role ensures resolutions are consistent with department, regulatory, and accreditation guidelines, and are handled timely and efficiently. This position works closely with clinical, coding and reimbursement, claims, customer contact center, and other areas as needed to ensure resolution of requests.

Your responsibilities will include

• Reviews emergent and standard appeal requests and makes appropriate determination of steps required to complete the appeal using knowledge, judgement, expertise, and standards of practice according to applicable appeal procedures.
• Ensures claims are reprocessed following appeal determinations and adjusted with high accuracy.
• Monitors multiple appeal timelines to ensure all required standards are met.
• Creates and sends appropriate appeals letters to members, providers, or other authorized appellants.
• Ensures proper follow up with member, provider, or authorized appellant to gather additional information.
• Interacts with various areas/individuals of the organization to research and solve pending appeals and provides back-up support for affiliate department tasks.
• Participates in departmental and corporate initiatives by participating in improvement committees that assess current processes for procedural and efficiency improvements.
• Participates in a rotating on-call schedule for holidays and weekends.
• Identifies patterns through appeals received for potential provider education opportunities as well as internal education to various areas.
• Works closely with the liaison for North Dakota Insurance Department as well as directly with the North Dakota Insurance Department on specific types of requests.
• Collaborates with various vendors initiating communications and submitting on-line appeals through their portals.

What you need to succeed

• High School Diploma/GED with 3 years of claims and/or call center experience.
• Appeals experience a plus!
• A good level of accuracy and attention to the details.
• Strong written communication skills with the ability to collaborate with other team members.
• Ability to prioritize work, follow timelines and reprioritize as needed.
• Enjoys a fast-paced work environment.

Equivalent combination of education, experience or training determined to be acceptable by Human Resources may be substituted, unless regulated by contract or program standards

Benefits

• Affordable medical, dental and vision coverage accepted throughout the United States
• Employer funded Lifestyle Spending Accounts, Health Savings Accounts and Health Reimbursement Arrangements
• Employer-paid life and disability insurance
• 401(k) retirement plan with company match and immediate vesting
• Paid holidays, paid time off (PTO), PTO donation program, and paid parental leave
• Voluntary benefits including Accident, Hospital Indemnity, Critical Illness, Term/Whole Life, Cancer Care Insurance, and more.

Additional company perks

• Robust mental health offerings including an Employee Assistance Program, Learn to Live, meQ.
• Comprehensive learning and development opportunities and an Educational Assistance Program.
• 16 hours of paid volunteer time with a $200 donation to a charity of your choice upon completion of all volunteer hours.
• Employee recognition, community initiative events and yearly company outings.
• Workplace flexibility offering different options for working arrangements and the freedom to make time for important commitments.
• Opportunities to connect through employee committees.

Equal opportunity employment

Equal Opportunity Employer of Minorities, Females, Protected Veterans and Individual with Disabilities, as well as Sexual Orientation or Gender Identity.

For questions, please email [email protected].