Appeals Coordinator

This is a fully remote position, open to applicants in Pennsylvania.

📋 Description

• Provides assistance in the administration of the Appeals and Grievance process.

• Acts as a liaison between Members and the Plan concerning appeals related to denied claims/services, referrals, membership, and benefit issues, as well as concerns regarding the quality of care or service.

• Presents Member appeals to the Plan Medical Staff and contracted reviewers from the Center for Medicare/Medicaid Services.

• Prepares and manages Member appeals, complaints, and grievances by directly communicating with Members, their Representatives, Vendors, and Medical Providers, ensuring the necessary information is gathered to successfully complete the appeal process within the regulatory time frame.

• Investigates all aspects of appeals and complaints by consulting with healthcare providers, legal services, internal medical staff, and administration, among others.

• Provides timely and precise documentation of all communications with involved parties within both the individual case file and departmental tracking database.

• Ensures compliance with complaint, appeal, and grievance time frames as dictated by guidelines established by the Department of Labor (DOL), the Department of Health (DOH), the Department of Insurance (DOI), the National Committee for Quality Assurance (NCQA), and the Centers for Medicare and Medicaid Services (CMS).

• Implements regulatory updates to current practices, policies, and procedures within the Department.

• Maintains a comprehensive and accurate database using departmental software for reporting, tracking, and trending purposes.

• Conducts regular audits of personal files and data entries to guarantee timely, accurate, and appropriate documentation.

• Coordinates activities for review committees and educational sessions with other Health Plan departments to ensure overall compliance is upheld.

• Serves as the primary resource regarding the complaint, appeal, and grievance processes for all other Health Plan and external entities, maintaining communication with all parties involved throughout the appeals and grievance process.

• Adheres strictly to all applicable laws and regulations set forth by Federal and State regulatory bodies, continuously reviewing updates relevant to regulatory changes and implementing those adjustments within current departmental practices, policies, and procedures.

⛳️ Requirements

• High School Diploma or Equivalent (GED) - (Required)

• Minimum of 5 years of relevant experience* (Required)

• Skills: Communication, Multitasking, Working Independently

🏝️ Benefits

• We provide healthcare benefits for both full-time and part-time positions starting on day one, including vision, dental, and domestic partner benefits.

• Fosters an environment of collaboration, cooperation, and collegiality.