Coordinate appeals process as assigned, attends to risk management issues associated with utilization management appeal requests.
The Appeals Coordinator will work closely with the appeals unit clinical review staff, known as Appeal Nurses, to ensure timely and accurate processing of requests for post-determination review.
Maintains a caseload and monitors day to day compliance of appeal decision time frames.
Reviews clinical and medical records for completeness and determines administrative or clinical appeal.
Assigns reviews to physician advisers and medical directors for those requiring medical necessity reviews.
Enters all data related to appeals and case reviews into a database.
Prepares and presents information on appeals to panels second-level multi-disciplinary committee.
Participates in data gathering and analysis of reports regarding appeal activity as well as preparing for appeals audits, provides new employee training, monitors QI (Quality Improvement) activities of appeals department, and assists in the development of depart flows and implementations.
Coordinates and distributes first, second and third level appeal request assignments.
Consults with managers on problem cases and interfaces with case managers, clinical supervisors, account managers and other personnel in resolving denial and appeal questions.
Responds to member, provider, and client telephone inquiries regarding status, process and outcome of appeals.
Organizes volume of work and workflow so that performance standards and proper procedures for appeals resolution according to client requirements and state and federal regulations are addressed.
Claims experience and medical terminology knowledge & prior authorizations required.
There will be clerical piece, data entry, entering cases & research case components, as well.
1 year of experience in Customer Service and clinical appeals in a healthcare setting, HMO required
Virginia Premier Health Plan or Anthem previous employees would have applicable experience*
Experience with Microsoft Office Suite
Outstanding verbal communication skills, and proven track record in effective customer services relations required
Experience with reimbursement instruments (standard claim forms) and medical claims handling (provider or payor) preferred.
Knowledge of industry terminology (CPT and ICD-9 codes).