Appeals Coordinator

Summary: The Claims Appeals Coordinator is responsible for reviewing, analyzing and processing claims for pre services and post service grievances and appeals requests from customer types (i.e. member, provider, regulatory and third party) and multiple products (i.e. HMO, POS, PPO, EPO, CDHP, and indemnity) related to clinical and non-clinical services, quality of service and quality of care issues to include executive and regulatory grievances The Appeals Coordinator is in daily contact with team members, clients and providers. A cheerful, competent and compassionate attitude will directly impact the productivity of the team. Attendance can also directly impact the satisfaction level of our clients and retention of our accounts.

Essential Duties and Responsibilities

• Reviews, analyzes and processes non-complex grievances and appeals in accordance with external accreditation and regulatory requirements, internal policies and claims events requiring adaptation of written response in clear, understandable language.
• Utilizes guidelines and review tools to conduct extensive research and analyze the grievance and appeal issue(s) and pertinent claims and medical records to either approve or summarize and route leadership for review.
• The grievance and appeal work are subject to applicable accreditation and regulatory standards and requirements. As such, the coordinator will strictly follow department guidelines and tools to conduct their reviews.
• Analyzes and renders determinations on assigned non-complex grievance and appeal issues and completion of the respective written communication documents to convey the determination.
• Responsibilities exclude conducting any utilization or medical management review activities which require the interpretation of clinical information.
• Interpret Plan Documents and review appeals within guidelines and timeframes as determined by the clients plan coverage
• Maintain and or develop workflows with comprehensive notes with attention to detail to enable accurate claims processing related to appeals and or refunds
• Maintain quality and production standard when processing appeals and client refunds
• Exhibit an attention to detail and a strong work ethic
• Complete other duties as assigned.
• Regular, predictable attendance is required.
• Ability to get along and work effectively with others.

Supervisory Responsibilities: This job has no supervisory duties.

Salary Range: $20 - $25/hour (DOE)