Senior Coordinator, Complaint Appeals

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

📋 Description

• Accountable for resolving appeal scenarios across all product lines.

• Grow into a subject matter expert by delivering training, coaching, or addressing intricate issues.

• Investigate and resolve incoming electronic appeals as necessary.

• Capable of identifying and redirecting inappropriate work items.

• Compile all data utilized for making denial determinations.

• Examine standard plan design, coverage certification, and any potential contractual deviations.

• Able to assess a clinical determination and comprehend the rationale behind the decision.

• Proficient in researching claim processing logic and various systems.

• Collaborates with internal teams and across departments effectively.

• Recognizes trends and emerging issues, reporting on possible solutions.

• Conducts internal quality reviews and offers necessary support during audits and meetings.

• Understands and addresses Executive complaints and appeals as assigned.

⛳️ Requirements

• 1-2 years of experience in Medicare Part C Appeals.

• Familiarity with reading or researching benefit language in SPDs or COCs.

• Background in research and analysis of claim processing is an advantage.

• Proven ability to manage multiple assignments competently, accurately, and efficiently.

• Outstanding verbal and written communication skills.

• Exceptional customer service abilities.

• Experience in documenting workflows and reengineering efforts.

🏝️ Benefits

• Medical, dental, and vision coverage.

• Paid time off.

• Retirement savings options.

• Wellness programs.

• Additional resources based on eligibility.