Maintain a caseload and monitor day-to-day compliance of appeal decision time frames; review clinical and medical records to determine administrative or clinical appeal.
Assign reviews to physician advisers and medical directors; enter all data related to appeals into a database and prepare information for panels.
Coordinate first, second, and third level appeal assignments and participate in data gathering, analysis, audits, and quality improvement activities.
Respond to inquiries from members, providers, and clients regarding status, process, and outcome of appeals; organize workflow to meet client requirements and regulatory standards.
Job description
JOB DESCRIPTION: 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 work-flow so that performance standards and proper procedures for appeals resolution according to client requirements and state and federal regulations are addressed. RESPONSIBILITIES: Experience in customer interactions and detailed review of health related materials. Strong interpersonal skills and attention to detail. Ability to organize work and seek help on tasks where needed. Strong writing and proofing skills required ensuring documents meet standards and are accurate. WORK EXPERIENCE: Customer Service EDUCATION: High School Diploma or GED (Required), Associates (Preferred)REQUIRED SKILLS:Top 3 Must-Haves (Hard Skills)
Data Entry experience
Letter writing skills
Microsoft Suite
Case management experience Nice-To-Haves (Hard Skills)
Typing 50 WPM
Customer service
Healthcare experienceDegree Requirements High school diploma or GED
