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Provider Appeals Specialist
About the position
Healthy Careers Start Here At Blue Cross & Blue Shield of Mississippi, we encourage professional growth in a challenging and fast-paced atmosphere. Our 'be healthy' culture promotes health and wellness at all levels of the Company, and we provide our employees with the time, tools and resources to commit to a healthy lifestyle. The Provider Appeals Specialist is responsible for reviewing, researching, and making decisions on provider appeals to include Benefit, biometric, Physician allowance, Color Me Healthy and Coding appeals using the Plan documents and other resources, in a clear, concise and timely manner. The incumbent is accountable to apply coding expertise in handling coding appeals. The Provider Appeals Specialist is also responsible for composing provider responses that are educational in nature to prevent repeat appeals where possible. Also, as a daily function, the Provider Appeals Specialist is responsible for identifying quality improvement to ensure efficient business processes and accurate claims processing where deficiencies are noted in CAS page instructions, system edits, etc. Blue Cross & Blue Shield of Mississippi is an Equal opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability or protected veteran status. We offer a comprehensive benefits package that is worth approximately one-third of the salary compensation. Our benefits program is among the best in the health care field. We are looking for employees who can bring their experience, expertise and dedication to work for our customers. At Blue Cross & Blue Shield of Mississippi, we work daily to help Mississippians find their personal answers to this question through health and wellness partnerships with quality healthcare providers, employer groups and community leaders across the state. Our goal is to help each person along their journey to a healthier life… their Blue Wellness Journey. Our health and wellness benefits are designed to support our members in understanding their health and in receiving the care they need at the right time and place, beginning with establishing a healthy relationship with a Primary Care Network Provider through an annual wellness visit at no out-of-pocket cost. We partner with our Network Providers to ensure the highest quality, evidence-based care is provided in each care setting from primary care to specialty care through our Primary Care Home, Blue Distinction+ Centers of Excellence and Maternity Care Quality initiatives. We partner with employer groups to make every workplace a healthy workplace by providing tools and information to help employees take ownership of their health and understand and make the most of their benefits, all while working to manage health and healthcare costs. We partner with community leaders and organizations to make healthy living resources available to all Mississippians through the work of the Blue Cross & Blue Shield of Mississippi Foundation, our support of the arts and culture and our Team Blue volunteers. These partnerships and our dedicated team of employees are making a difference every day, in our communities and in the lives of each person we reach. So, what does it mean to be healthy? The answer is about you, your health, your life… and all its possibilities. Live healthy. Live Blue.
Responsibilities
- Reviewing, researching, and making decisions on provider appeals to include Benefit, biometric, Physician allowance, Color Me Healthy and Coding appeals using the Plan documents and other resources, in a clear, concise and timely manner.
- Accountable to apply coding expertise in handling coding appeals.
- Composing provider responses that are educational in nature to prevent repeat appeals where possible.
- Identifying quality improvement to ensure efficient business processes and accurate claims processing where deficiencies are noted in CAS page instructions, system edits, etc.
Requirements
- Bachelor's degree required.
- Twelve months of BCBSMS service or have at least one year of physician based coding experience.
- Excellent written communication skills required
- Strong analytical skills to investigate complex information
- Experience utilizing CAS preferred.
- Knowledge of Internal and External appeal regulations preferred.
- Knowledge of claims filing, office administration, or related organizational skills preferred.
- Must have strong PC skills and knowledge of computer applications to include Microsoft Word and Excel.
Nice-to-haves
- Multi-specialty coding experience is preferred.
Benefits
- We offer a comprehensive benefits package that is worth approximately one-third of the salary compensation.
- Our benefits program is among the best in the health care field.
