Appeals Specialist - St. Luke's Health Plan

At St. Luke’s Health Plan, we’re on a mission to connect people with affordable, hassle-free health care. We are the only health plan in Idaho putting doctors and insurance on the same team to deliver a more efficient and quality health care experience with less stress. Join us in this bold ambitious journey!

The Appeals Specialist for St. Lukes Health Plan is responsible for intake, investigation and resolution of appeals, complaints, and grievance scenarios for all products, which may contain multiple issue and may require coordination of responses from multiple business units. This role focuses on determining responses for commercial group and individual plans (including on and off exchange), self-funded plans (including ERISA and non-ERISA), and Medicare Advantage plans. The Appeals Specialist ensures timely, accurate, and fair outcomes while supporting member satisfaction and maintaining compliance.

Duties/Responsibilities:
-Manages the investigation and resolution of general appeals and grievances in compliance with regulatory requirements and company policies.
-Prepares and facilitates Member appeals, complaints, and grievances by communicating directly with Members, their Representatives, Vendors and Medical Providers and their Representatives to obtain the necessary information to complete the appeal process successfully.
-Conducts thorough investigations to complete comprehensive reviews, often collaborating with internal departments to gather necessary information. When necessary, triage incomplete components of appeals, complaints, and grievance to appropriate subject matter expert within another business unit for resolutions response content to be included in final resolution response.
-Drafts clear, accurate, and timely correspondence to members and providers. Ensures timely, customer focused response to appeals, complaints and grievances including the notice of determination. Identifies and reports trends and emerging issues and provides recommend solutions.
-Maintains precise documentation of all activities, decisions, and correspondence in the system.
-Ensures appropriate routing of appeals and grievances during all steps of the process.
-Maintains knowledge of and adheres to all applicable laws and regulations for appeals and grievances set forth by Federal and State regulatory bodies. Communicates updates to laws and regulations to appropriate stakeholders.
-Maintains a complete and accurate database via departmental software for reporting and tracking and trending purposes.
-Serves as a technical resource to colleagues regarding appeals, complaints and grievance issues, and similar situations requiring a higher level of expertise.
Recommends improvements and modifications to departmental operating procedures to maximize operating efficiency.

Education: Bachelors degree or experience in lieu of a degree            Experience: 2 years relevant experience                                          Licenses/Certifications: None

At St. Luke’s, caring for people in the communities we serve is our mission – and this includes our own SLHS team. We offer a robust benefits package to support our teams both professionally and personally. In addition to a competitive salary and retirement plans, we ensure our team feels supported in their benefits beyond the typical medical, dental, and vision offerings. We care about you and have fantastic financial and physical wellness options, such as: on-site massages, on-site counseling via our Employee Assistance Program, access to the Virgin Pulse Wellness tool, as well as other formal training and career development offerings to ensure you are meeting your career goals.

St. Luke’s is an equal opportunity employer and does not discriminate against any person on the basis of race, religion, color, gender, gender identity, sexual orientation, age, national origin, disability, veteran status, or any other status or condition protected by law.

*Please note: this posting is not reflective of all job duties and responsibilities and is intended to provide an overview to job seekers.