• Job Description

  Req#: R-38430
  The primary responsibility of this position is to triage/intake all department work and load into systems timely to be assigned to the Member Appeals & Grievance Analysts to be worked. The incumbent will also be responsible for making phone calls to request supporting case information, fax requests, and preparing case files for Imaging and all other support duties. This includes assurance that all actions are appropriate according to the Centers for Medicare & Medical Services (CMS) regulations and guidelines.

  Job Description:

  BlueCross, as a federal contractor, may be required to implement a COVID-19 vaccine mandate.

  Job Responsibilities

  • Receive, triage, and distribute work from all sources including hardcopy mail, fax, multiple GM mailboxes, Imaging, department Quality Improvement Organization-fast appeals calls, etc. and documenting the substance of the appeal or grievance/complaint in all applicable systems according to timeliness requirements. Utilize multiple systems in order to appropriately document the substance of the appeals, grievance or complaint. Reroute correspondence as applicable.
  • Following up with members and/or providers regarding additional information needs including medical records and Appointment of Representative Forms. This includes detailed documentation of all related Facets inquiries information, claims, utilization management, and case management notes as well as the member’s benefits.
  • Mail and fax all departmental outgoing correspondence timely according to CMS notification requirements.
  • Maintain knowledge of CMS regulations and guidelines affecting the appeal/grievance/complaint process.
  • Identifying information that needs to be rerouted to the appropriate person or area, ensuring that all work has been accurately distributed each day.

  Job Qualifications

  Education

  • High School Diploma or equivalent

  Experience

  • 1 year - Experience in claims or customer service required

  Skills\Certifications

  • Attention to detail, exceptional documentation abilities, and organizational skills
  • Exceptional time management skills
  • If current employee with the company, must meet minimum performance expectations
  • Excellent oral and written communication skills
  • Strong interpersonal and organizational skills
  • Ability to manage multiple projects and numerous personnel simultaneously
  • Knowledge of CMS regulations and guidelines related to appeals, grievances and complaints
  • Proficient with Facets, CareAdvance and Imaging

  Job Specific Requirements:

  Preference will be given to candidates with Medicare experience and/or candidates with experience in the SR Care Appeals and Grievance Department.

  This position requires the employee to work onsite 50% of the time. This is an office-based position with ability to work from home every other week. However, will need to work onsite as need to provide coverage when others are unavailable.

  Preferred Skills:

  Number of Openings Available:

  1

  Worker Type:

  Employee

  Worker Sub-Type:

  Employee

  Company:

  BCBST BlueCross BlueShield of Tennessee, Inc.

  Applying for this job indicates your acknowledgement and understanding of the following statements:

  BCBST is an Equal Opportunity employer (EEO), and all employees and applicants will be entitled to equal employment opportunities when employment decisions are made. BCBST will take affirmative action to recruit, hire, train and promote individuals in all job classifications without regard to race, religion, color, age, sex, national origin, citizenship, pregnancy, veteran status, sexual orientation, physical or mental disability, gender identity, or any other characteristic protected by applicable law.

  Further information regarding BCBST's EEO Policies/Notices may be found by reviewing the following page:

  BCBST's EEO Policies/Notices

  BlueCross BlueShield of Tennessee is not accepting unsolicited assistance from search firms for this employment opportunity. All resumes submitted by search firms to any employee at BlueCross BlueShield of Tennessee via-email, the Internet or any other method without a valid, written Direct Placement Agreement in place for this position from BlueCross BlueShield of Tennessee HR/Talent Acquisition will not be considered. No fee will be paid in the event the applicant is hired by BlueCross BlueShield of Tennessee as a result of the referral or through other means.

  All applicants will be advised that BlueCross, as a federal contractor, may be required to implement a COVID-19 vaccine mandate .

  Tobacco-Free Hiring Statement

  To further our mission of peace of mind through better health, effective 2017, BlueCross BlueShield of Tennessee and its subsidiaries no longer hire individuals who use tobacco or nicotine products (including but not limited to cigarettes, cigars, pipe tobacco, snuff, chewing tobacco, gum, patch, lozenges and electronic or smokeless cigarettes) in any form in Tennessee and where state law permits. A tobacco or nicotine free hiring practice is part of an effort to combat serious diseases, as well as to promote health and wellness for our employees and our community. All offers of employment will be contingent upon passing a background check which includes an illegal drug and tobacco/nicotine test. An individual whose post offer screening result is positive for illegal drugs or tobacco/nicotine and/or whose background check is verified to be unsatisfactory, will be disqualified from employment, the job offer will be withdrawn, and they may be disqualified from applying for employment for six (6) months from the date of the post offer screening results.

  Resources to help individuals discontinue the use of tobacco/nicotine products include smokefree.gov or 1-800-QUIT-NOW.

• About the company

  BlueCross BlueShield of Tennessee is the largest health benefit plan company in Tennessee.

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