Role Description
The Appeals Coordinator gathers all information required for an appeal, writes, and submits the appeal to the insurance company, makes follow-up phone calls, and maintains documentation of all steps taken. The Appeals Coordinator uses clinical criteria guidelines and clinical documentation to develop sound and well-supported appeal arguments to support medical necessity. The Appeals Coordinator works independently and collaboratively with other departments to positively affect clinical and financial outcomes.
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Display knowledge of clinical pertinence and managed care requirements to support medical necessity criteria for inpatient and outpatient levels of care.
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Verify the information needed by the insurance plan for an appeal, where to submit the appeal, and method of submitting appeal.
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Manage large volumes of documents including copying, faxing and scanning incoming mail.
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Document and log information on tracking systems and mainframe systems.
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Ensure appeals are completed thoroughly and on a timely basis.
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Interface with managed care organizations, external reviews, and other payers.
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Obtain access to various provider portals and utilize portals for submitting appeals and following up on status of appeals when applicable.
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Communicate with facility UR staff when needed to efficiently complete the appeal process.
Qualifications
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Bachelor’s Degree in social work, RN or degree in a related behavioral health field.
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Minimum of 2 years of experience in a managed care/healthcare setting.
Requirements
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Previous utilization review experience in a psychiatric healthcare facility preferred.
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Computer proficiency in Microsoft Office applications and other software programs essential to perform job functions.
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May be required to work flexible hours and overtime.
Benefits
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Comprehensive Benefits: Multiple levels of medical, dental and vision coverage for full-time and part-time employees.
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Financial Protection & PTO: Life, accident, critical illness, hospital indemnity insurance, short- and long-term disability, paid family leave and paid time off.
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Financial & Career Growth: Higher education and certification tuition assistance, loan assistance and 401(k) retirement package and company match.
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Employee Well-being: Mental, physical, and financial wellness programs (free gym memberships, virtual care appointments, mental health services and discount programs).
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Professional Development: Ongoing learning and career advancement opportunities.
