Appeals Coordinator

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

📋 Description

• Manage and document all elements of appeal cases, encompassing receipt date and time, investigation of appeal substance, and associated records, comments, or information.

• Grasp and implement standards set by NCQA, URAC, DOL, CMS, along with federal and state regulations.

• Comprehend member and provider rights and obligations related to claims and appeals.

• Support Appeals Specialists in the daily operations of the Appeals Department.

• Investigate and record appeals and claims in accordance with regulatory mandates, business practices, and departmental guidelines.

• Aid in achieving accurate determinations and issuing compliant notifications.

• Oversee appeal workflows and monitor turnaround times.

• Ensure thorough and precise case documentation, facilitating timely case resolutions.

• Collaborate with Appeals Specialists, customer service, and reimbursement teams.

• Engage with members, providers, health plans, and internal stakeholders, escalating issues as necessary.

• Uphold standards of regulatory compliance, organizational policies, ethical practices, confidentiality, and security.

• Achieve productivity, accuracy, and turnaround time targets.

⛳️ Requirements

• An associate degree and over a year of pertinent healthcare experience.

• A combination of education and relevant healthcare appeals, claims, utilization management, or health plan experience may be accepted in lieu of a degree, including a high school diploma with 3+ years of relevant healthcare experience.

• A minimum of 1 year of experience in healthcare appeals, claims, utilization management, or related health plan fields.

• Proficient in Microsoft Office Suite (Word, Excel, Outlook, etc.) and appeals documentation systems.

• Solid understanding of applicable federal and state regulations, accreditation standards, privacy, confidentiality, and security requirements pertaining to healthcare information.

• Ability to pass a background check upon hire and throughout employment, covering criminal, employment, education, sanctions, prohibited parties, sex offender registry, and a 10-panel drug screening.

• Proven adaptability and flexibility to evolving processes and various software applications.

• Capability to handle multiple priorities within a fast-paced setting.

• Professional demeanor with the ability to collaborate with various levels of professionals and staff.

• Ability to contribute positively to team dynamics and lead team initiatives.

• Strong problem-solving, organizational, and attention-to-detail skills.

• Must work from a designated home office; travel between multiple residences or remote work locations is not permitted.

• High-speed internet connection with a minimum download speed of 20 Mbps, upload speed of 5 Mbps, and maximum latency of 100 milliseconds, to be set up prior to starting.

• A quiet workspace with minimal background noise for calls.

🏝️ Benefits

• Comprehensive health benefit options: Medical, dental, and vision coverage.

• 401(k) with a competitive employer match.

• Company-paid life and disability insurance.

• Paid parental leave and wellbeing incentives.

• Generous paid time off, including time for volunteering.

• Flexible spending accounts for healthcare and dependent care.

• Opportunities for professional development and tuition reimbursement.

• Remote work flexibility (role dependent).

• Possibility for significant personal and professional growth.

• Company-provided equipment.