Senior Appeals Coordinator
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POST DATE 9/11/2020
END DATE 9/20/2020
Magellan Health Services
San Diego, CA
JOB DESCRIPTIONCandidates must be local to San Diego, CA office.
Performs research and analysis of appeals filed by members, customers, and government entities to administer timely resolution within state and federal guidelines, benefit plan guidelines, and company policies and procedures. Maintains a caseload of appeals and performs assigned duties. * Analyzes and renders final decisions of non-clinical appeals according to procedure, state and federal guidelines, benefit plan guidelines, company internal policies and work flows.
* Coordinates the appeal and dispute process through the collection of clinical records and consultation with Physician Advisors/Medical Director and communicates final determination.
* Familiar with and can assist in coordinating peer review scheduling involving internal Physician Advisors and external vendors.
* Consults with internal departments such as Clinical, Legal, and Network, as well as company senior management to assure appeal and complaint decisions meet all guidelines and result in customer satisfaction when possible.
* Consults with Account Management and external vendors to resolve high profile, complex appeals and/or complaints.
* Responsible for preparation of written detailed case history and presentation of second level appeal cases to the Appeals Panel for final company determination.
* Documents process and findings within the Appeals and the Complaint databases, and internal systems.
* Responsible for interface with members and providers as required regarding status, process and outcomes of complaints and appeals.
* Responsible for maintaining the integrity of the company relationship with customers by researching, resolving and responding to customer inquiries for appeals, disputes and scheduling issues.
* Responsible for identifying risk situations, consulting with senior management staff and rendering determinations that could adversely affect the company.
* Researches, compiles and consults with external review organization and customers as necessary for appeals and complaint process.
* Assists in data gathering and reporting of appeals. Responsible for achieving and maintaining department performance guarantees.
* Assists in developing workflows and innovative process improvements to positively impact the department overall.
* Contributes to unit and department CQI (continuous quality improvement) processes by participating in unit goal setting, scorecard development and departmental meetings. Meets individual performance standards.
* Other duties as assigned.
RESPONSIBILITIES * 2+ YEARS EXPERIENCE IN PROCESSING APPEALS AND/OR CLAIMS.
* EXPERIENCE WORKING IN A CONTACT CENTER ENVIRONMENT.
* 2+ YEARS BEHAVIORAL HEALTH, HEALTHCARE OR MANAGED CARE INDUSTRY EXPERIENCE.
* ABILITY TO TALK ON THE TELEPHONE AND TYPE ON A COMPUTER SIMULTANEOUSLY.
* WORKING KNOWLEDGE MICROSOFT PRODUCT SUITE.
* ABILITY AND WILLINGNESS TO LEARN NEW SOFTWARE APPLICATIONS.
MAGELLAN HEALTH SERVICES IS PROUD TO BE AN EQUAL OPPORTUNITY EMPLOYER AND A TOBACCO-FREE WORKPLACE. EOE/M/F/VET/DISABLED. EVERY EMPLOYEE MUST UNDERSTAND, COMPLY AND ATTEST TO THE SECURITY RESPONSIBILITIES AND SECURITY CONTROLS UNIQUE TO THEIR POSITION.