INSURANCE ANALYST Healthcare Appeals

DEPARTMENT OF INSURANCE AND FINANCIAL INSTITUTIONS

The Department of Insurance and Financial Institutions licenses monitors investigates examines and ensures the safety and soundness of regulated entities. The Department also helps resolve consumer complaints against financial-services and insurance entities; takes action in response to violations of law; encourages competition innovation and economic development; collects taxes and assessments that support State government operations; combats auto theft and insurance fraud through public awareness campaigns and funding for law enforcement and dedicated prosecutors.

Our mission is to help Arizonans receive the benefits and protections to which they are legally entitled by enforcing insurance and financial institution laws by providing information and assistance and to combat vehicle theft.

INSURANCE ANALYST - HEALTHCARE APPEALS

Job Location :

Market Conduct and Consumer Services Division

This position may offer the ability to work remotely within Arizona based upon the departments business needs and continual meeting of expected performance measures.

100 North 15th Avenue

Phoenix AZ 85007

Posting Details :

Salary : $50000 - $53500

Grade : 20

Closing Date : 12 / 12 / 2025

Job Summary :

The Department (DIFI) is required to administer the health care appeals laws. The laws allow members to request review of denied services or claims as not medically necessary or not covered in the health insurance policy. DIFI makes the determination for policy coverage disputes while cases involving medical-necessity are sent by DIFI to independent review organizations.

This position may offer the ability to work remotely within Arizona based upon the departments business needs and continual meeting of expected performance measures.

The State of Arizona strives for a work culture that affords employees flexibility autonomy and trust. Across our many agencies boards and commissions many State employees participate in the States Remote Work Program and are able to work remotely in their homes in offices and in hoteling spaces. All work including remote work should be performed within Arizona unless an exception is properly authorized in advance.

Job Duties :

Process enrollee and provider requests for health care appeals including making determinations on coverage cases; selecting independent reviewers and referring medical-necessity cases for external review; researching statutes and medical and insurance reference materials; obtaining relevant information from insurers providers and enrollees; tracking and responding to case deadlines; coordinate with agency accounting staff to invoice health insurers for HCA cases requiring external review.

Perform document and portal management activities to ensure consistency and accuracy of reports. Collect track and compile data and prepare reports. Assist with preparation of content and maintenance of health care appeals and surprise out of network billing web pages.

Review enrollee requests for SOON billing arbitration; obtain relevant information from insurers providers and enrollees and / or their representatives; determine eligibility for the arbitration process; arrange the informal settlement teleconference; assign arbitrator(s) after verifying absence of conflict; monitor cases for compliance with statutory timelines; refer / educate as appropriate to federal No Surprises Act resources.

Assist with preparation and editing of operational and action plans policies procedures systems and forms; develop informational resources regarding HCA- and SOONBDR-related issues; coordinate with other divisions to provide technical advice on health care and surprise billing issues; serve as an informed source on all technical matters related to appeals and surprise billing disputes.

Participate in developing requests for proposal to procure independent medical review organizations; participate in developing any necessary amendments to current IRO contracts; participate in providing quality or utilization data to State Procurement Office in furtherance of state IRO contracts.

Respond to calls inquiries and emails about the health care appeals and surprise out of network dispute resolution process. Create form letters and email templates and edit as appropriate to communicate with enrollees insurers and providers.

Knowledge Skills & Abilities (KSAs) :

Knowledge :

Arizona health insurance laws rules and policies including expertise in the standards for surprise out-of-network billing arbitration and health care appeals.

General principles of statutory construction.

Arizona health insurance market industry practices medical terminology types of health conditions types of medical treatment types of durable medical equipment types of medicines and insurance company operations.

Federal laws regulations and programs and the administration of those programs that pertain to and / or effect the business and transaction of health insurance.

Policy processes procedures systems forms and instructions and other resources for performing job responsibilities.

Protocols for contacting and dealing with insurance company provider and billing staff and representatives.

Skills :

Time-management project organization and problem-solving.

Time-management project organization and problem-solving.

Regulatory analysis.

Developing and maintaining effective professional interpersonal working relationships.

Reading and interpreting state and federal laws and regulations and insurance contract provisions.

Communicating clearly and effectively both verbally and in writing.

Employing discretion and diplomacy in dealing with outside parties.

Providing superior customer service.

Using word processing spreadsheets Google Mail Google Team Drive Google Docs PDF and comparable programs.

Ability :

Analyze complex / conflicting data documents insurance contract language draw valid conclusions and adopt and implement an effective course of action.

Quickly grasp complex subject matter prioritize assignments and to work autonomously.

Exercise good judgment and make appropriate decisions.

Interpret and explain complicated information to others.

Establish and maintain effective and professional working relationships with stakeholders insurers health care providers coworkers and consumers.

Communicate diplomatically clearly and effectively in writing and verbally.

Plan organize and coordinate activities with others.

Adapt to new and changing circumstances.

Selective Preference(s) :

A minimum of 2 years of work experience in insurance in a customer-service capacity.

Pre-Employment Requirements :

All newly hired State employees are subject to and must successfully complete the Electronic Employment Eligibility Verification Program (E-Verify).

Benefits :

The State of Arizona offers a comprehensive benefits package to include :

Optional employee benefits include short-term disability insurance deferred compensation plans and supplemental life insurance

Life insurance and long-term disability insurance

Vacation plus 10 paid holidays per year

Health and dental insurance

Retirement plan

Sick leave

Paid Parental leave

Remote work is a management option and not an employee entitlement or right. An agency may terminate a remote work agreement at its discretion.

For a complete list of benefits provided by The State of Arizona please visit our benefits page.

Retirement :

Positions in this classification participate in the Arizona State Retirement System (ASRS)

Please note that enrollment eligibility will become effective after 27 weeks of employment

Contact Us :

If you have any questions please feel free to contact Debbie Muhlestein @

Required Experience :

IC

Key Skills

Civil,Apparel,Banking,CMS,Insulation

Employment Type : Full-Time

Experience : years

Vacancy : 1

Monthly Salary Salary : 50000 - 53500