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Job Description: Summary: Manages submission, intervention and resolution of appeals, grievances, and/or complaints from Client members and related outside agencies as a part of the integrated Healthcare Services Team. Conducts pertinent research, evaluates, responds and completes appeals and other inquiries accurately, timely and in accordance with all established regulatory guidelines. Prepares appeal summaries and correspondence and documents information for tracking/trending data.
Essential Functions: Enters denials and requests for appeal into information system and prepares documentation for further review. Researches issues utilizing systems and clinical assessment skills, knowledge and approved Decision Support Tools in the decision making process regarding health care services and care provided to members. Assure timeliness and appropriateness of all Provider appeals according to state and federal and Client Healthcare guidelines. Request and obtain medical records, notes, and/or detailed bills as appropriate to assist with research. Evaluates for medical necessity and appropriate levels of care and formulates conclusions per protocol. Collaborates with Medical Directors and other team members to determine appropriate responses. Obtains Medical Director approval for determination per Client protocol. Work with Customer Service to resolve balance bill issues and other member complaints regarding providers. Prepare responses to provider grievances / appeals. Elevates appeals to the appropriate committee and/or manager per protocol. Prepares and assists in the preparation of the narratives, graphs, flowcharts, etc. to be utilized for presentations and audits. Coordinates workflow between departments and interface with internal and external resources. Receive and resolve provider inquiries related to claims. Act as a liaison between the providers and health plan as appropriate. Assist with interdepartmental issues to help coordinate problem solving in an efficient and timely manner. Identifies and refers cases appropriately for Health Management, Case Management, Quality Improvement and Health Education per established triggers. Documents referral according to Client Healthcare process. Creates and/or maintains statistics and reporting.
Knowledge/Skills/Abilities: Comprehensive knowledge of health care customer service, regulatory requirements and Provider Dispute and/or Member Appeal process.
Knowledge of CPT/HCPC and ICD9 coding, procedures and guidelines. Comprehensive clinical decision logic and analysis skills. Excellent vocabulary, grammar, spelling, punctuation, and composition skills proven through the development of written communication. Maintain regular attendance based on agreed-upon schedule Computer skills and experience with Microsoft Office Products. Excellent verbal and written communication skills Ability to abide by Clients policies Maintain confidentiality and comply with Health Insurance Portability and Accountability Act (HIPAA) and fraud and abuse prevention detection policies and procedures Ability to establish and maintain positive and effective work relationships with coworkers, clients, members, providers and customers.
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