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Detailed description of the position: Summary of Position: This position provides analytical problem-solving support to the Commercial and Medicare Appeals and Grievances staff and serves as a central point of contact for staff both inside and outside of Appeals and Grievances. uses knowledge of current business practices, policies, systems, procedures, and testing tools and practices to provide and guarantee innovative solutions to business problems. -Offers an analysis of the department's performance metrics and policies from other operational areas. contributes to the department's development, implementation, upkeep, and monitoring of ongoing product and regulatory support. -Assists in the coordination of activities related to maintaining regulatory compliance, such as the proactive evaluation of ongoing compliance, the examination of laws and regulations, and the evaluation and identification of areas that require modification or change to comply with laws and regulations. analyzes, researches, makes suggestions for, and implements changes to processing procedures to make the department's overall operations more efficient and to easily meet deadline requirements. all training and documentation efforts are supported. Qualifications and responsibilities: Essential Duties and Responsibilities Leads and represents the department on inter-departmental projects, including all major system enhancements, for departmental process improvements and projects. translates and/or interprets technical material for use in everyday appeals. responds to questions and concerns raised by a variety of employees in appeals, other Plan departments, and external business partners. carries out a variety of varied tasks that are related to job responsibilities (such as meetings, biweekly reports, new developments, and so on). Offers help to the division by helping with investigating/settling specialty requests as mentioned by the executives and handles different obligations as allocated. Contributes to the research, evaluation, organization, and creation of policies and procedures based on the identified training requirements in order to facilitate a more efficient response to Facets inquiries in both correspondence applications and appeals. serves as the unit's subject matter expert for Facets' customer service inquiry module and appeals module configuration. Preparing up-to-date, in-depth exercises and labs for new employees and supporting refresher training contributes to the training. assists in the preparation and evaluation of corporate and regulatory requirements for compliance with federal and state regulations. through data analysis and reporting, supports data validation and universe pulls. is the department's subject matter expert for Medicare and commercial compliance activities. aides in the department's research and resolution of independent analysis-identified trends when requested by management. Furthermore, the incumbent may: As assigned, conduct peer reviews and document findings; Support the audit; Mentor new employees and employees undergoing cross-training at the desk; As dictated by workload, provide peers with functional training. Receives and analyzes performance metrics and other forms of communication from other departments, as well as provides assistance to external vendors, in order to ascertain the impact on the department and the actions that are required. assists with programs for training. frequently communicates in order to share resources with training staff and management. demonstrates support for established company policies and procedures regarding service appeals. arranges any necessary additional materials. provides the department with technical support for all PC and LAN systems, including Windows, the mainframe, MS Office, FACETS, PBM, and other systems that require access. blue cross blue shield data entry Apply To This Job Apply tot his job Apply To this Job
