Description:Appeals Coordinator
At Coventry, we've been building a world-class Customer Service Organization that delivers an easy and simple experience for our customers. We need the right people on the front line to make a difference with our members, health care providers and even each other as we work together as a team.
If you are looking for a career in the health care industry, but prefer an office environment, this could be the right opportunity for you. We are currently recruiting an Appeals Coordinator in our Moon Township, PA Service Center. The ideal candidate will serves as single point of contact and subject matter expert to provide support and advocacy to Medicare members for resolution of Medicare grievances. Coordinates, audits and investigates the overall grievance resolution process by evaluating and resolving verbal and/or written complaints from members in compliance with federal, state, and organizational grievance procedure guidelines.
We offer a competitive salary, excellent benefits (401K with company matching, paid training, comprehensive benefits including medical, dental, tuition reimbursement), vacation and sick time, and a business casual environment. This is a fast-paced, hands-on, team-oriented environment where creativity, initiative, and innovation are highly rewarded.
Qualifications:
ESSENTIAL RESPONSIBILITIES
Responsible for collecting, organizing, and tracking information to facilitate and expedite member appeals.
Review appeals to determine what additional documentation is needed to make an appropriate decision. Contact providers to request information or more detailed explanation of services rendered.
Research administrative or non-clinical aspects of the appeal.
Research member information in response to difficult inquiries, including, but not limited to, authorizations, payments, denials, coordination of benefits.
Resolve difficult issues to achieve member satisfaction.
Prepare files for review by a Pharmacist, Medical Director and/or Appeals Committee.
Ensure all Medicare Compliance measures, including but not limited to timeliness, are met. Maintain all documentation associated with processing and handling of appeals and grievances
to comply with regulatory standards while maintaining an accurate, complete appeals/grievance
records.
Perform comprehensive research related to the facts and circumstances of a member complaint to include appropriate classification as a grievance, appeal or both, and implementation of applicable processes as mandated by CMS.
Work closely with medical management and or pharmacy staff to obtain clinical information for appeals related to the denial of services and or medication.
Serve as a liaison in corresponding and communicating with providers and members or the
member’s representative.
Perform comprehensive research related to the facts and circumstances of a member complaint to include appropriate classification as a grievance, appeal or both, and implementation of applicable processes as mandated by CMS.
Responsible for the application of contract language, benefits and covered services from the Evidence of Coverage in researching and deciding the outcome in cases of grievances and appeals.
Review, understand, and interpret annual Medicare Chapter Guidance for both managed care and prescription drug services
Lead, support and facilitate meetings for special projects and workgroups.
Identify business problems and initiate corrective measures; direct servicing issues to appropriate area for corrective action.
JOB SPECIFICATIONS
High school diploma or equivalent experience.
Previous (1-2 years) experience in Medicare, Medicaid Enrollment and or claims.
Previous experience processing and working with all types of insurance products including HMO, PPO, and Indemnity under both fully insured and self-funded arrangements.
Knowledge of medical terminology required.
Preferred:
Bachelors degree or equivalent experience preferred.
Previous pharmacy experience.
Other skills:
Strong written and verbal communication skills
Excellent data analysis and interpretation capabilities
Outstanding organization skills and ability to meet deadlines
Strong problem-solving techniques
Professional in demeanor and appearance
Ability to function as an effective team member
Coventry Health Care is an Affirmative Action/Equal Opportunity Employer, and we are committed to building a talented and diverse team.
Job: Administrative Support Workers
Primary Location: Moon Township, PA, US
Organization: 10750 - Service Center - Central Admin
Schedule: Full-time
Job Posting: 2013-02-07 00:00:00.0
Job ID: 1310454
