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 department's business needs and continual meeting of expected performance measures.

100 North 15th Avenue
Phoenix, AZ 85007

Posting Details:

Salary: $50,000 - $53,500 

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 department's 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 State’s 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.