Service Advocate V (Appeals & Disputes)

What You Will Be Doing

• Reviews appeal requests from members and providers in accordance with BCBSF policies and procedures, regulatory guidelines, and timelines.
• Solves grievances, appeals or disputes involving expressions of dissatisfaction, reimbursement, medical necessity, ClaimCheck®, Utilization Management, and Fee for Service payments within regulatory timeframes for all lines of business except SAO & FEP.
• Researches and resolves provider data loads.
• Lets medical records and form CMS-1500 on Enterprise Imaging or Imaginator for clinical review or to verify proper coding (modifiers and procedure codes).
• Accesses various web-based and other applications to review how claim was originally paid by BCBSF.
• Researches and documents all issues and findings.
• Enters appeal or dispute determinations into various BCFS systems and SQL databases.
• Fulfills regulatory requirements as appropriate and corporate values, policies and procedures.
• Ensures final determination with statement that supports determination is communicated to provider within required timelines.
• Completes customized correspondence with appropriate statement that supports final determination.
• Fulfills strict timelines for communicating final determination.
• Documents final disposition of dispute into BCFS systems and SQL databases.
• Facilitates escalated calls and issues from providers and members regarding appeals or dispute decisions.

What We Require

• 3+ years related work experience combination of transferable experience and education.
• Experience Details: Service, regulatory, critical inquiry, audit, or compliance
• High school diploma or GED
• Experience using Microsoft Office, including Word, Excel and PowerPoint.
• Experience using BCFS's member benefit booklets, reimbursement, medical necessity, fee for service and ClaimCheck® payment concepts, practices, and procedures.
• Experience using various inquiry and claim payment systems (e.g., Legacy, Diamond, Siebel, PIP, TSO, Convergence, Network Contracting, Medical Coverage Guidelines, CMCA, MBSP, etc.) to research grievance, appeals or disputes.
• Experience entering grievance, appeal or dispute determinations into various BCFS systems and SQL databases.
• Ability to follow regulatory requirements as appropriate and corporate values, policies and procedures.
• Demonstrated ability to interact with internal and external customers in a highly professional manner.
• Knowledge of ERISA and HIPAA.
• Knowledge of regulatory agency requirements, as appropriate.
• Ability to work within strict timeframes.