Appeals Coordinator

JOB Title: Appeals Coordinator

Duration: 6 + months contract to hire position.
Location: San Diego CA 92108

Requirements/Certifications:

·HS/GED.

·1-2 years of appeals/claims/scheduling or coordination experience (a plus if all 3).

·Managed Care experience is a PLUS.

·Schedule: Monday-Friday 8:30AM - 5:00PM PST.

·6 month contract with possibility of conversion depending upon performance.

JOB SUMMARY:

Responsible for processing and recording appeals and/or provider disputes as well as coordinating scheduling with internal and external PA reviewers for determinations and appeals. Provides high level of accuracy and quality in produced materials and interactions with members and providers.

ESSENTIAL FUNCTIONS:

·Maintain a caseload of appeals, non-authorizations, provider disputes and/or PA review scheduling as assigned- Process appeals, non-authorizations and provider disputes according to policies, work flows

·Document process and findings within database

·Contact and respond to members and providers within required timeframes as required by contracts, regulations and standards.

·Prepare written materials following policies and procedures for notification and tracking purposes of appeals, provider disputes and PA review scheduling.

·Identify risk areas and reports such to unit manager

·Consult with manager on problem cases and interfaces with unit staff in data obtainment and resolution.

·Prepare and present information on non-authorizations, appeals and provider disputes to external review organizations and customers.

·Assist in data gathering and reporting of non-authorizations, appeals and provider disputes.

·Contribute to CMC/Client’s office and department CQI processes by participating in unit goal setting, scorecard development and departmental meetings.