Appeals Coordinator

Position: Appeals Coordinator

Job Type:                    Full-time

Status:                         Non-Exempt

Location:                    NJ, Remote

Medlogix, LLC delivers innovative medical claims solutions through a seamless collaboration of our Medlogix® technology, our highly skilled staff, access to our premier health care provider networks, and our commitment to keeping our clients’ needs as our top priority. Medlogix has a powerful mix of medical expertise, proven processes and innovative technology that delivers a more efficient, disciplined insurance claims process. The result is lower expenses and increased productivity for the auto insurance and workers’ compensation insurance carriers; third party administrators (TPAs); and government entities we serve.

OVERVIEW: 

Review and respond to New Jersey PIP bill appeals in accordance with NJ Department of Banking and Insurance. As an appeals representative, your duties are to perform bill review analysis, document the process as it moves through our system, provide support for New Jersey arbitration, and knowledge of PPO contract interpretation. Must be familiar with NJ regulations and NJ PIP handling.

ESSENTIAL DUTIES AND RESPONSIBILITIES:

• Conducts detailed appeal investigation of all supporting documents and systems to determine if the appeal should be upheld or overturned based on all available facts.
• Proactively communicates with appellants, leadership team, providers and the original case manager to resolve investigation issues, resolve issues and communicate decisions/rationale for denial/approval.
• Retrieve assigned cases from queue and based on analysis of issues determine appropriate classification.
• Validate all assigned cases; review appeal documents, correct appeal types, timeframes and what is being appealed.
• Employee is responsible for tracking internal due dates and timeframes so that the Compliance timeframes are met.
• Document all actions taken during review for auditing and reporting purposes.
• Assist the Manager/Supervisor in identifying root cause of issues related to appeals.
• Performs other duties as assigned or required

REQUIRED SKILLS AND QUALIFICATIONS:

• The ability to consistently apply appropriate administrative and regulatory criteria for reviewing and making decisions on all non-clinical appeals and validating the accuracy of all received information.
• Effective communication abilities (written and verbal) when documenting actions and communications with Members, Providers, Medical Director and appeals leadership.
• 1-2 Years’ experience with New Jersey No Fault regulations related to Appeals, Claims and PIP billing
• Working knowledge of Automobile fee schedule
• Strong written and verbal communications skills
• Proven ability to analyze detailed information
• Proficient with Microsoft Office suite, Excel, Word
• Dealing with Ambiguity
• Priority Setting
• Learning and Applying Quickly
• Problem Solving
• Perseverance
• Requires more than 1-3 years’ experience to include appeals, billing, claims, customer service; familiarity with state and federal regulations, medical terminology, and coding.

EDCUATION REQUIREMENTS:

EEOC STATEMENT:

Medlogix is an Equal Opportunity Employer. Medlogix does not discriminate on the basis of race, religion, color, sex, gender identity, sexual orientation, age, disability, national origin, veteran status or any other basis covered by appropriate law. We will continue to maintain our commitment to making all employment-related decisions based on the merit of each individual.