Base pay is influenced by several factors including a candidate’s qualifications, relevant experience, and anticipated contributions to meet the needs of the business, along with internal pay equity and external market driven rates. The salary range displayed has not been adjusted for geographical location. This range has been created in good faith based on information known to Capital Blue Cross at the time of posting and may be modified in the future. Capital Blue Cross offers a comprehensive benefits packaging including Medical, Dental & Vision coverage, a Retirement Plan, generous time off including Paid Time Off, Holidays, and Volunteer time off, an Incentive Plan, Tuition Reimbursement, and more.
At Capital Blue Cross, we promise to go the extra mile for our team and our community. This promise is at the heart of our culture, and it’s why our employees consistently vote us one of the “Best Places to Work in PA.” 

 

This position acts as a central point of contact for staff within and outside Appeals and Grievances, and provides analytical problem-solving support to the Commercial and Medicare Appeals and Grievances staff. Uses knowledge of existing business practices, systems, procedures, policies, current testing tools/practices and their inter-relationships to provide and ensure innovative approaches and solutions to business problems. Provides an analysis of other operational areas' policies and procedures and performance metrics that impact the department. Assists in the development, implementation, maintenance, and monitoring of effective and continuing product and regulatory support for the department. Coordinates activities associated with maintaining regulatory compliance, including proactive assessment of ongoing compliance, reviewing laws/regulations and the assessment and identification of areas requiring change and/or modification to comply with laws/regulations. Researches, analyzes, recommends, and implements changes to processing procedures to increase efficacy of the overall operations of the department and meet timeliness requirement with ease. Supports all training and documentation efforts.

• 30% - Leads departmental process improvements and projects, represents the department on inter-departmental projects, including all major system enhancements. Interprets and/or translates technical material for day-to-day appeals use. Responds to inquiries and issues presented by various staff within appeals, from other departments within the Plan as well as from external business partners.
• 15% - Performs various miscellaneous duties related to job responsibilities (e.g., meetings, bi-weekly reports, new developments, etc.) Provides support to the department by assisting in researching/resolving specialty inquiries as requested by management and handles other duties as assigned.
• 15% - Assists with the research, evaluation, organization, and development of policies and procedures based on the training needs identified in order to facilitate more effective processing of Facets inquiries in both the Appeals and Correspondence Applications.
• 10% - Serves as the unit’s subject matter expert on appeals module configuration and interaction with the customer service inquiry module within Facets. Assists the training by preparing updated and detailed exercises/labs for new staff and to support refresher training.
• 10% - Assists with preparation and analysis of Regulatory and Corporate needs necessary for compliance to Federal and State Regulations. Supports data validation and universe pulls through reporting and data analysis. Serves as the department subject matter expert for compliance activities, both Medicare and commercial.
• 5% - Provides support to the department by assisting in researching/resolving trends identified by independent analysis and as requested by management. Additionally the incumbent may:
  • Conduct peer reviews and document findings as assigned
  • Provide audit support
  • Provide desk mentoring for new staff and staff undergoing cross-training
  • Provide functional training for peers, as required by workload
• 5% - Receives and evaluates performance metrics and other communication material from other departments and support external vendors to determine departmental impact and required action.
• 5% - Assists with training programs. Interacts frequently with training staff and management to share resources.
• 5% - Promotes and reinforces approved company policies and procedures relative to servicing appeals. Arranges supplemental materials as needed. Provides technical support to the department for all PC and LAN systems including Windows, mainframe, MS Office, Visual Basic macros, FACETS, PBM and other systems access warranted.

Skills:

• Comprehensive understanding of all Capital Blue Cross benefit programs and products, Medicare and Commercial.
• Significant experience in the utilization of a PC and related software (e.g., Microsoft Office Suite).
• Oral and written communication skills in order to effectively present ideas/findings/recommendations and exchange information with all types of audiences (e.g., technical and non-technical), as well as prepare clear and thorough documentation as necessary.
• Ability to work effectively independently and in groups, set priorities, and adjust to changing workload requirements.
• Demonstrated above average verbal and written Communication Skills.
• Demonstrated ability to coordinate, prioritize and organize task with minimal supervision.
• Demonstrated competency in Windows (Outlook, Word, Internet Explorer, Excel and PowerPoint)
• Demonstrated ability to navigate in FACETS/Customer Service & Appeals various modules.
• Demonstrated technical acumen to understand supporting configuration and business requirement development.

Knowledge:

• Knowledge of manual operations, policies, and procedures used throughout the Company and their relationship to the department.
• Knowledge of Federal and State Regulatory requirements surrounding Appeals. (e.g. Medicare, Act 68, ERISA, HIPAA, NCQA)
• Knowledge of the activities and special processing procedures used in appeals resolution.
• Demonstrate leadership and ethical behavior in an informal reporting relationship.
• Demonstrated strong knowledge of CBC Medicare Advantage and Part D benefit programs.

Experience:

• 3 years of Appeals and Grievances experience.
• Advanced work experience with a PC and various software applications (i.e. Microsoft Office Suite).

Education and Certifications:

• Bachelors degree in business administration, health care administration, information systems or a related field or equivalent demonstrated work experience of no less than three years.
• High School degree and demonstrated work experience of no less than three years is required.

Work Environment: 

• Sedentary work involving significant periods of sitting, talking, hearing, keying and performing repetitive motions.
• Work requires visual acuity to perform close inspection of written and computer generated documents as well as a PC monitor.
• Working environment includes typical office conditions.

 

Physical Demands:

• While performing the duties of the job, the employee is frequently required to sit, use hands and fingers, talk, hear, and see. The employee must be able to work 37.5 hours per week.
• The employee must occasionally lift and/or move up to 5 pounds.

Other:

• Facets, Bridges, Workflow, appeals manual, Microsoft Office (Outlook, Word, Excel, PowerPoint, Internet), SharePoint, Crystal, STARS, CAPS, check reconciliation, Clarity, Business Object, Swiftview, delegated administration, RadMD, Blue 2 and Work Desk. The PBM systems. CMS systems.

We recognize that work is a part of life, not separate from it, and foster a flexible environment where your health and wellbeing are prioritized. At Capital you will work alongside a caring team of supportive colleagues, and be encouraged to volunteer in your community.  We value your professional and personal growth by investing heavily in training and continuing education, so you have the tools to do your best as you develop your career. And by doing your best, you’ll help us live our mission of improving the health and well-being of our members and the communities in which they live.