The Appeals intake coordinator position is focused on the processing of incoming member and provider Medicare appeals and grievances. This team member will screen incoming complaints and appeals for level of urgency, benefit or medical necessity issues and other appropriate inquiries. This team member will assign the incoming concern to the appropriate analyst and may assist in investigations, documentation gathering, and correspondence as needed. This team member may also participate in auditing and monitoring activities as assigned. This team member will promote quality member care and customer service/satisfaction.
This team member will interact with Customer Service, Utilization Management, Medical Directors, and other internal teams as necessary to effectively triage incoming complaints and appeals.
Essential Functions:
Review and triage incoming Medicare appeals and grievances based on urgency and type of concern.
Assign incoming complaints, appeals, and inquiries to the appropriate analyst for review and resolution.
Assist with investigations, documentation collection, and correspondence related to appeals and grievances.
Correspond with members, providers, and regulatory agencies regarding decisions and actions.
Collaborate with Customer Service, Utilization Management, Medical Directors, and other internal teams to effectively manage incoming concerns.
Participate in auditing and monitoring activities as assigned.
Communicate, collaborate, and cooperate with internal and external stakeholders.
Promote quality member care and customer service satisfaction.
Adhere to all compliance requirements and HIPAA regulations.
Support departmental goals that contribute to the overall success of the organization.
Education:
High School Diploma or equivalent required.
Experience:
Minimum of one (1) year of health insurance or managed care experience performing Appeals and Grievances functions.
Knowledge, Skills, and Abilities:
Knowledge of healthcare delivery systems.
Ability to work in a fast-paced environment with changing priorities.
Strong collaboration and teamwork skills.
Effective written communication skills.
Strong time management and prioritization skills.
Demonstrated problem-solving abilities.
Strong organizational skills and attention to detail.
Ability to identify and define problems, gather and analyze information, establish facts, draw valid conclusions, and implement changes related to federal regulations.
Technical Skills:
Proficiency with Microsoft Office applications.
Experience with Health Edge, Epic, and/or Facets preferred.