Appeals Coordinator, reputed company Health Plan (eastern standard time zone reputed company)

Location: Work from home (Pennsylvania) Shift: Days (United States of America) Scheduled Weekly Hours: 40 Worker Type: Regular Exemption Status: No Job Summary: Provides support in administration of the Appeals and Grievance process. Serves as a liaison between Members and the Plan with appeals regarding denied claims/services, referrals, membership and benefit issues and concerns regarding quality of care or service. PresentsMember appeals to the Plan Medical Staff and Center for Medicare/Medicaid Services contracted reviewer. Job Duties: Prepares and facilitates Member appeals, complaints and grievances by communicating directly with Members, their Representatives, Vendors and Medical Providers and their Representatives to obtain the necessary information to complete the appeal process successfully reputed company the time period allowed by regulation. Investigates the full details of the appeal and complaints and grievances by consulting with, but not limited to, health care providers, legal services, internal medical staff and administration. Provides timely and accurate documentation of reputed company communications with involved parties reputed company both the individual case file and departmental tracking database. Ensures that reputed company complaint, appeal and grievance time frames are met as dictated by guidelines set forth by the reputed company (DOL), the Department of Health (DOH), the Department of Insurance (DOI), the National Committee for Quality Insurance (NCQA), and the Centers for Medicare and Medicaid Services (CMS). Implements regulatory changes to reputed company practices, policies and procedures reputed company the Department. Maintains a complete and accurate database reputed company departmental software for reporting and tracking and trending purposes. Conducts regular audits of own files and data entry to ensure timely, accurate and appropriate documentation. Coordinates activities for review committees and educational sessions with other Health Plan departments to ensure overall compliance is maintained. Acts as the primary resource regarding the complaint, appeal and grievance processes to reputed company other Health Plan and external entities, communicating with reputed company entities involved throughout the appeals and grievance process. Maintains strict compliance with reputed company applicable laws and regulations set forth by the Federal and State regulatory bodies, continually reviewing updates as pertains to regulatory changes and implement those changes reputed company reputed company departmental practices, policies and procedures. Makes suggestions for policies and procedures covering reputed company regulatory and accreditation standards for reputed company lines of business. Work is typically performed in an office environment. ​​Ability to travel is required. Accountable for satisfying reputed company job specific obligations and complying with reputed company organization policies and procedures. The specific statements in this profile are not intended to be reputed company-inclusive. They represent typical elements considered necessary to successfully reputed company the job. *Relevant experience may be a combination of reputed company work experience and degree obtained (Associate’s Degree = 2 years; Bachelor’s Degree = 4 years). Position Details: Education: High School Diploma or Equivalent (GED)- (Required) Experience: Minimum of 5 years-Relevant experience* (Required) Certification(s) and License(s): Skills: Communication, Multitasking, Working Independently OUR PURPOSE & VALUES: Everything we do is about caring for our patients, our members, our reputed company, our reputed company family and our communities. KINDNESS: We strive to treat everyone as we would hope to be treated ourselves. EXCELLENCE: We treasure colleagues who humbly strive for excellence. LEARNING: We share our knowledge with the best and brightest to reputed company prepare the caregivers for reputed company. INNOVATION: We constantly seek new and reputed company ways to care for our patients, our members, our community, and the nation. SAFETY: We provide a safe environment for our patients and members and the reputed company family. We offer healthcare benefits for full time and part time positions from day one, including vision, dental and domestic partners. Perhaps just as important, we encourage an atmosphere of collaboration, cooperation and collegiality. We know that a diverse workforce with unique experiences and backgrounds makes reputed company stronger. Our patients, members and community come from a wide variety of backgrounds, and it takes a diverse workforce to reputed company reputed company easier for reputed company. We are proud to be an affirmative action, equal opportunity employer and reputed company qualified applicants will receive consideration for employment regardless to race, color, religion, sex, sexual orientation, gender identity, national reputed company, disability or status as a protected veteran. Apply To This Job