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Job Details

Appeals & Health Benefits Analyst I

Requisition #: 208824
Location: Johns Hopkins Health Care, Hanover, MD 21076
Category: Non-Clinical Professional
Work Shift: Day Shift
Work Week: Full Time (40 hours)
Weekend Work Required: No
Date Posted: Dec. 25, 2019

Regularly communicates with both internal and external customers concerning benefit interpretation, appeals and claims issues. Researches incoming appeals and prepares written response. Uses knowledge of Priority Partners, Employee Health Program, and Uniformed Services Family Health Plan (USFHP) regulations, claims, appeals, insurance regulations and managed care to explain procedures to vendors, providers and customers. Acts as a resource for claims, customer service, care management and sites. Responsible for review and payment determination of claims pended for determination/resolution or clarification of authorizations for Priority Partners, USFHP and EHP claims.

REQUIREMENTS:

Education:

  • Associates degree in business management, health care administration or related discipline. Equivalent experience may be substituted for degree.

Knowledge:

  • Requires thorough knowledge of administrative procedures, understanding of medical terminology in addition to CPT codes and ICD-9 codes & revenue codes.
  • Requires knowledge of managed care/insurance benefits, billing guidelines, and contracting as well as appeals rights and responsibilities.
  • Must be able to read and interpret providers contracts and members summary plan descriptions (SPDs).
  • Current knowledge of regulations and guidelines for insurance complaints and understanding how to research regulation guidelines, as generally acquired in three years of managed care insurance setting. Knowledge of medical claims processing and coding.
  • Knowledgeable in the nuances and interrelationships of all JHHC products.

Skills:

  • Proficient PC skills, Microsoft Word, Microsoft Excel, and knowledge of claim research in MC400, and IDX claims systems, and MSR/CMS Care Management systems.
  • Excellent communications skills both orally and written.
  • Requires strong analytical skills to gather information from different sources and to resolve moderately complex problems.
  • Must have the ability to work independently, and to handle multiple tasks concurrently.
  • Must be able to write letters to members and providers explaining our determination. Excellent oral and written communication skills.

Work Experience:

  • Work requires a minimum of three years’ experience in the health care delivery system or insurance setting. Experience should include managed care/claims, appeals experience. Problem solving, data gathering and interpretation, as well as insurance/managed care benefits and procedures for appeals and claims processing.

Johns Hopkins Health System and its affiliates are an Equal Opportunity / Affirmative Action employers. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity and expression, age, national origin, mental or physical disability, genetic information, veteran status, or any other status protected by federal, state, or local law.

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