Coordinates appeals process as assigned, attends to risk management issues associated with case management and processes appeal requests. In some cases may be combined with Grievance Coordinator functions.
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.
Other Job Requirements
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.
General Job Information
Title
Appeals Coordinator - Remote
Grade
18
Work Experience - Required
Customer Service
Work Experience - Preferred
Education - Required
GED, High School
Education - Preferred
Associates
License and Certifications - Required
License and Certifications - Preferred
Magellan Health, Inc. is proud to be an Equal Opportunity Employer and a Tobacco-free workplace. EOE/M/F/Vet/Disabled.Every employee must understand, comply with and attest to the security responsibilities and security controls unique to their position; and comply with all applicable legal, regulatory, and contractual requirements and internal policies and procedures.
