Senior Coordinator Complaint Appeals Operations

Senior Coordinator Complaint Appeals Operations

Requirements

• 1-2 years Medicare part C Appeals experience.
• 1 years experience in reading or researching benefit language in SPDs or COCs.
• 1 years of experience in research and analysis of claim processing.
• Demonstrated ability to handle multiple assignments competently, accurately and efficiently.
• Excellent verbal and written communication skills.
• Computer navigation ability and ability to multitask.
• Excellent customer service skills.
• Strong Leadership skills
• Experience documenting workflows and reengineering efforts.

Responsibilities

• Research and resolves incoming electronic appeals as appropriate as a ‘single-point-of-contact’ based on type of appeal.
• Can identify and reroute inappropriate work items that do not meet complaint/appeal criteria as well as identify trends in misrouted work.
• Assemble all data used in making denial determinations and can act as subject matter expert with regards to unit workflows, fiduciary responsibility and appeals processes and procedures.
• Research standard plan design, certification of coverage and potential contractual deviations to determine the accuracy and appropriateness of a benefit/administrative denial.
• Can review a clinical determination and understand rationale for decision.
• Able to research claim processing logic and various systems to verify accuracy of claim payment, member eligibility data, billing/payment status, and prior to initiation of the appeal process.
• Serves as point person for newer staff in answering questions associated with claims/customer service systems and products.
• Educates team mates as well as other areas on all components within member or provider/practitioner complaints/appeals for all products and services.
• Coordinates efforts both internally and across departments to successfully resolve claims research, SPD/COC interpretation, letter content, state or federal regulatory language, triaging of complaint/appeal issues, and similar situations requiring a higher level of expertise.
• Identifies trends and emerging issues and reports on and gives input on potential solutions.
• Delivers internal quality reviews, provides appropriate support in third party audits, customer meetings, regulatory meetings and consultant meetings when required.
• Understands and can respond to Executive complaints and appeals, Department of Insurance, Department of Health or Attorney General complaints or appeals on behalf of members or providers as assigned.

Preferred Qualifications

• Project management skills are preferred.
• Strong knowledge of all case types including all specialty case types