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Capital Blue Cross is a healthcare and insurance organization serving individuals, families, employers, and communities in Central Pennsylvania and the Lehigh Valley. Its offerings include health plans, Medicare coverage, student health plans, and resources designed to help members navigate medical care. The company focuses on accessible coverage, preventive health, and ongoing support for members’ broader wellness needs.
Medicare Appeals Analyst
Support Capital Blue Cross’s Medicare and commercial appeals operations through regulatory analysis, FACETS expertise, reporting, staff training, and process improvement.
Description
- Serve as a key contact for colleagues across Appeals and Grievances and other teams.
- Provide analytical problem-solving support to commercial and Medicare appeals staff.
- Review departmental policies, procedures, and performance measures.
- Develop, maintain, and monitor product and regulatory support.
- Coordinate compliance work, assess adherence, and review applicable laws and regulations.
- Research and implement changes to appeals processing procedures.
- Contribute to staff training and documentation.
- Lead departmental improvement initiatives and projects.
- Represent the department in cross-functional projects and major system upgrades.
- Explain technical information for practical use in appeals work.
- Answer questions from colleagues, other departments, and external business partners.
- Investigate specialized inquiries and emerging trends, and help resolve them.
- Develop and organize policies and procedures in response to training needs.
- Act as the subject matter expert on FACETS appeals configuration and its connection to the customer service inquiry module.
- Create exercises and practice labs for new-hire and refresher training.
- Support compliance reviews, data validation, universe pulls, reporting, and analysis.
- Review peers’ work, record findings, and provide audit support and mentoring.
- Deliver functional training to colleagues.
- Assess performance measures and communications from other departments and external vendors.
- Support training programs and coordinate resources with training staff and management.
- Reinforce approved company policies and procedures.
- Provide technical support for PCs, LAN systems, Windows, mainframe, Microsoft Office, Visual Basic macros, FACETS, PBM, and related systems.
Requirements
- At least three years of Appeals and Grievances experience.
- Advanced experience using PCs and software applications, including Microsoft Office.
- Bachelor’s degree in business administration, health care administration, information systems, or a related field, or equivalent demonstrated work experience of at least three years.
- High school diploma and demonstrated work experience of at least three years.
- Thorough understanding of Capital Blue Cross benefit programs and products, Medicare, and commercial coverage.
- Knowledge of federal and state appeals regulations, including Medicare, Act 68, ERISA, HIPAA, and NCQA requirements.
- Strong verbal and written communication skills.
- Proficiency with Windows, Outlook, Word, Internet Explorer, Excel, and PowerPoint.
- Ability to use FACETS Customer Service and Appeals modules.
- Technical aptitude to understand system configuration and develop business requirements.
- Knowledge of company manual operations, policies, and procedures.
- Knowledge of appeals resolution procedures.
- Ability to work independently and collaboratively, prioritize tasks, and adjust to changing workloads.
- Availability to work 37.5 hours per week.
Benefits
- Medical, dental, and vision coverage.
- Retirement plan.
- Paid time off.
- Paid holidays.
- Volunteer time off.
- Incentive plan.
- Tuition reimbursement.
- Flexible work environment.
- Training and continuing education.
- Community volunteering opportunities.
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