Appeals Coordinator

ESSENTIAL DUTIES AND RESPONSIBILITIES: 

• Create patient specific appeal letters by incorporating the reason of medical necessity for why the denial should be overturned.
• Coordinate prescriber review and signature of completed letters.
• Prepare and submit appeal documentation to insurance companies.
• Communicate with patients, healthcare providers, and insurance companies to gather necessary information.
• Work closely with provider office point of contact(s) to obtain updated information in order to create appeals, draft letters, as well as follow pharmacy workflow steps to provide a streamlined appeal process for offices and payers.
• Maintain accurate and up-to-date records of all appeals processed
• Process fax queues, emails, answer incoming calls and adhere to all thresholds for authorization management.
• Monitor appeal deadlines and ensure timely submission of all required documents.
• Input accurate and clear data entry of call logs, important case notes and authorization details into CRM system.
• Collaborate with internal departments to ensure comprehensive appeal support.
• Research and stay current with changes in healthcare policies and regulations.
• Provide status updates and resolution outcomes to involved parties.
• Develop and implement strategies to improve the appeals process.
• Assist in training new staff members on the appeals process.
• Verify the accuracy and quality of data entry within authorizations prior to submission.
• To safeguard, protect, and always demonstrate proper handling of protected health information in accordance with all HIPAA laws and company policies/procedures.
• Assess, prioritize and resolve client issues using good listening and comprehension skills.
• Works cooperatively and provides coverage for responsibilities of co-workers when assigned or as the need arises.
• Demonstrate working knowledge of all facets of the role, relevant regulations & organizational and departmental policies & procedures.
• Escalate issues to management as appropriate.
• Perform other duties as assigned to support the business.

QUALIFICATIONS AND REQUIREMENTS: 

• Strong understanding of medical terminology, insurance plans and authorization processes.
• Bilingual English/Spanish is a plus.
• Bachelor’s degree in healthcare administration, business or related field or minimum 3 year working in a healthcare setting managing or interpreting patient clinical notes or EMR files.
• Excellent written and verbal communication skills.
• Strong analytical and problem-solving skills.
• Previous experience in healthcare appeals or related field preferred.
• Working in a fast-paced environment for 2+ years is required.
• High level attention to detail and accuracy, with excellent investigative and research abilities.
• Strong customer service orientation.
• Ability to manage cases from multiple clientele programs and follow program business rules.
• Proficiency with data entry functions and Microsoft applications required.
• Ability to work independently and on a team
• Excellent communication, problem solving and customer service skills.
• Strong organizational /interpersonal skills; attention to detail and the ability to multitask proficiently.
• Ability to use multiple PC monitors and navigate through several.

PHYSICAL DEMANDS:
Requires sitting, standing, and occasional light lifting.

ProMod Rx will never ask for a financial commitment from an applicant, as part of our recruitment process.  All interviews are conducted in-person OR through video conference invitations from official company emails.  For inquiries, please contact our official recruitment team at

HR@procarerx.com

ProMod Rx is an Equal Opportunity Employer.