Appeals Specialist I

Appeal Specialist I

Work from home Within Oregon, Washington, Idaho or Utah

Build a career with purpose. Join our Cause to create a person-focused and economically sustainable health care system.

Who We Are Looking For:

Every day, Cambia's dedicated Appeal Specialist, are living our mission to make healthcare easier and lives better. As a member of the Appeals team, our Appeal Specialist Responsible for all activities associated with requests for Provider Billing Disputes and Appeals. Includes analysis, preparation, evaluation of prior determinations, coordination of clinical review if needed, decision making, notification, and completion. Follows guidelines outlined by subscriber or provider contracts, company documents, government mandates, other appeals regulatory requirements and internal policies and procedures. Provides information and assistance to members, providers, other insurance companies, and attorneys or others regarding benefits and claims. Does not make final clinical decisions but has access to licensed health professionals who conduct clinical reviews for appeals, all in service of creating a person-focused health care experience.

Do you have a passion for serving others and learning new things? Do you thrive as part of a collaborative, caring team? Then this role may be the perfect fit.

What You Bring to Cambia:

Qualifications:

• High school diploma or GED required
• Minimum 4 years' experience in Customer Service, Claims, or Clinical Services, or equivalent combination of education and work experience
• Coding Certification (CPC, CCS, or similar) preferred

Skills and Attributes:

• Excellent verbal and written communication skills with ability to present complex medical and reimbursement information diplomatically and persuasively regarding health plan benefits, claims, and eligibility
• Intermediate computer skills including Microsoft Word, Excel, and Outlook, with experience using Regence systems
• Knowledge of medical terminology, anatomy, and coding systems (CPT, DX, HCPCs) along with understanding of claims processing and clinical services operations
• Demonstrated initiative and analytical ability in identifying problems, researching issues, developing solutions, and implementing effective courses of action
• Ability to listen and communicate appropriately in a manner that promotes positive, professional interaction while maintaining confidentiality and sensitivity in all internal and external contacts
• Ability to switch from one task or type of work to another as business needs require while effectively prioritizing work to meet strict timelines and maintaining quality and consumer-centric focus
• Experience with AI tools and technologies to enhance productivity and decision-making in professional settings highly desired

What You Will Do at Cambia:

• Validate intake determinations regarding timeliness, member benefits, employer group, and provider contract provisions for each appeal and document information in appropriate system
• Review claim coding, claim processing history, medical policy, reimbursement policies, regulatory and legal requirements, benefit contracts, and provider contracts; collect and catalogue supporting documentation; formulate appeal recommendations; answer increasingly complex inquiries from members, providers, and representatives; collaborate with coding specialists, appeal nurses, physician reviewers, and others to reach timely decisions
• Make non-clinical appeal determinations as permitted by department business processes and guidelines; follow processes to receive clinical review and decisions from licensed health professionals; present complex cases to appeal panels; document decisions and communicate determinations to members, providers, or their representatives in appropriate system(s)
• Oversee set-up of appeals for external review organizations including document collection and coordination, communication with all parties, and serve as intermediary between provider and external review organization; prepare letters and cases for external review; implement external review decisions and ensure documentation in appropriate system
• Provide information, education, and assistance to members, providers, and their representatives; facilitate understanding of the appeal process and information necessary for effective processing; serve as courteous advocate when requesting supporting information; work cooperatively across all business areas to resolve issues and may perform as expert witness during any level of appeal regarding policies, procedures, and appeal rights
• Track appeals in appropriate systems and assist in maintenance of files; compile reports on appeals including trends, number of cases, decisions, process improvement suggestions, types of appeals, and compliance with timelines; manage defined caseload within department productivity and quality expectations and provide backup for other appeals staff
• Support, apply, and promote Provider or Member Appeal Policies and Procedures; adhere to dependability, customer focus, and all performance criteria including timeliness, production, and quality standards; meet timeliness standards as set forth through department policies, subscriber summary plan descriptions, performance guarantees, and regulations

#LI - Remote

The expected hiring range for an Appeal Specialist I is $25.90 - $37.30 an hour depending on skills, experience, education, and training; relevant licensure / certifications; and performance history. The bonus target for this position is 5%. The current full hourly range for this role is $24.40 - $42.20 an hour

About Cambia

Working at Cambia means being part of a purpose-driven, award-winning culture built on trust and innovation anchored in our 100+ year history. Our caring and supportive colleagues are some of the best and brightest in the industry, innovating together toward sustainable, person-focused health care. Whether we're helping members, lending a hand to a colleague or volunteering in our communities, our compassion, empathy and team spirit always shine through.

Why Join the Cambia Team?

At Cambia, you can:

• Work alongside diverse teams building cutting-edge solutions to transform health care.
• Earn a competitive salary and enjoy generous benefits while doing work that changes lives.
• Grow your career with a company committed to helping you succeed.
• Give back to your community by participating in Cambia-supported outreach programs.
• Connect with colleagues who share similar interests and backgrounds through our employee resource groups.

We believe a career at Cambia is more than just a paycheck - and your compensation should be too. Our compensation package includes competitive base pay as well as a market-leading 401(k) with a significant company match, bonus opportunities and more.

In exchange for helping members live healthy lives, we offer benefits that empower you to do the same. Just a few highlights include:

• Medical, dental and vision coverage for employees and their eligible family members, including mental health benefits.
• Annual employer contribution to a health savings account.
• Generous paid time off varying by role and tenure in addition to 10 company-paid holidays.
• Market-leading retirement plan including a company match on employee 401(k) contributions, with a potential discretionary contribution based on company performance (no vesting period).
• Up to 12 weeks of paid parental time off (eligibility requires 12 months of continuous service with Cambia immediately preceding leave).
• Award-winning wellness programs that reward you for participation.
• Employee Assistance Fund for those in need.
• Commute and parking benefits.

Learn more about our benefits.

We are happy to offer work from home options for most of our roles. To take advantage of this flexible option, we require employees to have a wired internet connection that is not satellite or cellular and internet service with a minimum upload speed of 5Mb and a minimum download speed of 10 Mb.

We are an Equal Opportunity employer dedicated to a drug and tobacco-free workplace. All qualified applicants will receive consideration for employment without regard to race, color, national origin, religion, age, sex, sexual orientation, gender identity, disability, protected veteran status or any other status protected by law. A background check is required.

If you need accommodation for any part of the application process because of a medical condition or disability, please email CambiaCareers@cambiahealth.com. Information about how Cambia Health Solutions collects, uses, and discloses information is available in our Privacy Policy.