The Pennsylvania Employees Benefit Trust Fund (PEBTF), administrator of health benefits for Commonwealth of Pennsylvania employees and retirees, has an immediate opening for an Appeals Resolution Program Administrator.

This position reports to Chief Operations Officer and is responsible for ensuring compliance with PEBTF department appeal policies to meet the needs of the membership and ensure the PEBTF meets operational goals and metrics.

The Appeals Resolution Administrator investigates, prepares, presents, and finalizes appeal cases in compliance with Departmental policy and defined timelines. Interacts with internal sources such as peers, Management, PEBTF members and external sources such as Trust Fund Trustees, Commonwealth, Union representatives, Vendors, Office of Inspector General etc.

This position also supports the Eligibility Committee; case preparation, internal review, Committee support, meeting minutes and post determination case completion.

The successful candidate will perform the following tasks:

Appeals

• Responsible for daily management of Appeals and Correspondence. This includes
• workflow, work product quality and management of employees engaged in responding to member appeals.
• Process appeal cases including evaluating, preparing, and finalizing appeal cases in compliance with Departmental policy and defined timelines.

• Support Eligibility Committee through investigating and preparing cases, presenting appeal cases at prep meetings and Committee meetings, completing meeting minutes and performing case completion activities.
• Represent the Department in appeal investigation and resolution. Coordinate with internal and external sources maintaining professional and HIPAA compliant communication.
• Process appeal determinations timely with letters that accurately reflect the decision in a manner the member can understand with a professional format.
• Maintain accurate appeal reports and share them with management staff on a routine basis. Monitor appeals and provide senior management with monthly reporting on trends.
• Manage Medicare Secondary Payer (MSP) cases; working with vendors as necessary to process requests and respond within the required timeframe.
• Run utilization data on appeal cases, requests from other Departments and in support of reporting needs.Management

• Manage staff and ensure compliance with policies, and processes to support operations.
• Act within the scope of authority and consistent with Fund objectives, guidelines, policies, and practices to manage appeals and mailroom functions.
• Monitor performance of direct reports and provide prompt and objective coaching and counseling as necessary.
• Manage the day-to-day relationships with internal and external business partners to resolve day-to-day appeal and issues and assure effective communications, prompt resolution of problems and report issues to Chief Operations Officer.
• Ensure compliance with HIPAA regulations and corporate Privacy and Security policies.
• Ensure that effective communications are maintained with internal and external sources.
• Ensure optimum performance of mailroom and appeal functions. Ensure work is completed accurate and timely.
• Recommend/implement techniques to improve productivity, increase efficiencies, reduce cost, and improve appeal and MSP case processing.
• Analyze departmental needs and assign personnel to meet the workload (i.e., peak vs. non-peak)
• Train, counsel, motivate, and appraise subordinates to include development of subordinates to perform to their utmost potential.
• Support staff; providing guidance and addressing issues.
• Maintain accurate unit/individual records (i.e., attendance, performance, quality, and quantity statistics) and other related employee documentation; prepares individual performance reports, time sheets, etc.
• Participate in interview and selection process for open positions.

Other

• Interact with Trust Fund personnel at all levels of the organization to coordinate and deliver high quality Appeal cases.
• Assist the Chief Operations Officer in the development of the annual budget to support appeal activities.
• Prepare reports for Management as requested.
• Perform other duties as assigned by PEBTF management.

These skills, knowledge and experience are required:

• Bachelor’s degree in a healthcare related field.
• Five to seven years of experience in the health insurance industry handling appeals, claims or other pertinent area.
• Three to five years managing a unit or department.
• Proven track record of innovation, organizational awareness and staff development and empowerment.
• Strong leadership skills including the ability to run group meetings and chair projects/initiatives.
• Excellent analysis skills and the ability to prepare detailed reports, statements, and projections.
• High regard for confidential information.
• Ability to establish credibility and be decisive but be able to recognize and support the Fund’s preferences and priorities.
• Ability to react quickly to changing priorities and job assignments.
• Proven ability to recruit, train, and motivate personnel.
• A commitment to customer service and a collaborative approach to problem solving.
• Comfortable performing multi-faceted projects in conjunction with normal activities.
• Travel is negligible.

Knowledge requirements:

• General business knowledge
• Excellent verbal and written communication skills
• Good interviewing skills
• Good knowledge of the healthcare insurance industry
• Strong interpersonal skills
• Good organization skills
• Excellent PC skills including Microsoft Office tools (Office365, Word, Excel PowerPoint, and Teams)
• Good keyboarding skills

We offer a competitive salary commensurate with background and experience, plus an excellent benefits package at the start of employment, a 401K retirement plan, tuition reimbursement, and a professional working environment.

PEBTF, an Equal Opportunity Employer, values the diversity of our workforce and the knowledge of our people.

Job Type: Full-time

Pay: $69,076.80 - $104,915.20 per year

Benefits:

• 401(k)
• Dental insurance
• Employee assistance program
• Flexible spending account
• Health insurance
• Life insurance
• Paid time off
• Tuition reimbursement
• Vision insurance

Schedule:

• 8 hour shift
• Day shift
• Monday to Friday

Ability to Commute:

• Harrisburg, PA 17111 (Required)

Work Location: Hybrid remote in Harrisburg, PA 17111