Service Advocate V – Appeals, Disputes

This is a fully remote position, open to applicants in Florida.

📋 Description

• Evaluates appeal requests from members and providers in line with BCBSF policies, procedures, regulatory guidelines, and established timelines. (15%)

• Addresses grievances, appeals, or disputes related to dissatisfaction, reimbursement, medical necessity, ClaimCheck®, Utilization Management, and Fee for Service payments within regulatory deadlines for all lines of business except SAO & FEP. (15%)

• Investigates and resolves issues pertaining to provider data loads. (5%)

• Retrieves medical records and CMS-1500 forms from Enterprise Imaging or Imaginator for clinical review or to confirm accurate coding (modifiers and procedure codes). (10%)

• Utilizes various web-based and other applications to examine how claims were initially processed by BCBSF. (5%)

• Conducts research and documents all issues and findings. (5%)

• Inputs appeal or dispute decisions into various BCBSF systems and SQL databases. (5%)

• Adheres to regulatory requirements as necessary and corporate values, policies, and procedures. (15%)

• Guarantees that the final determination, along with a supporting statement, is conveyed to the provider within the required timelines. (5%)

• Prepares customized correspondence with an appropriate statement supporting the final determination. (5%)

• Complies with strict timelines for communicating the final determination. (5%)

• Records the final resolution of disputes into BCBSF systems and SQL databases. (5%)

• Manages escalated calls and issues from providers and members regarding appeal or dispute decisions. (5%)

⛳️ Requirements

• 3+ years of relevant work experience combining transferable experience and education.

• High school diploma or GED.

• Proficiency in Microsoft Office, including Word, Excel, and PowerPoint.

• Familiarity with BCBSF'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, Medical Coverage Guidelines, CMCA, MBSP, etc.) to investigate grievances, appeals, or disputes.

• Proven experience in entering grievance, appeal, or dispute determinations into various BCBSF systems and SQL databases.

• Ability to adhere to regulatory requirements as necessary and corporate values, policies, and procedures.

• Demonstrated capability to engage with internal and external customers in a highly professional manner.

• Knowledge of ERISA and HIPAA regulations.

• Understanding of regulatory agency requirements, as applicable.

• Capacity to operate within strict timeframes.

🏝️ Benefits

• Medical, dental, vision, life, and global travel health insurance.

• Income protection benefits: life insurance, short- and long-term disability programs.

• Leave programs to accommodate personal circumstances.

• Retirement Savings Plan including employer match.

• Paid time off, volunteer time off, 10 holidays, and 2 well-being days.

• Additional voluntary benefits available; along with a comprehensive wellness program.