Independence Blue Cross, LLC
Philadelphia, PA
The Appeals Specialist is responsible for the timely, accurate, and compliant investigation and resolution of member and provider appeals and grievances. This role conducts comprehensive case research, evaluates applicable benefit plans, claims history, eligibility information, provider records, clinical or administrative documentation, and the circumstances surrounding an adverse determination. The Appeals Specialist prepares complete case files for clinical and/or administrative review, communicates case status and outcomes to internal and external stakeholders, and maintains clear documentation in designated systems. The position requires sound judgment, attention to detail, effective workload management, and consistent adherence to organizational policies, contractual requirements, and applicable regulatory standards and timeframes. • Conduct comprehensive research for assigned appeals and grievances, including review of enrollment and eligibility, provider participation...