Appeals & Disputes Coord - AZ

Manages the Provider Dispute and Member Appeal process from receipt to resolution including research, analysis and communication. Processes disputes and appeals in a timely and accurate manner, meeting or exceeding regulator timeliness requirements. Handles claim dispute and appeal cases of all levels of complexity across all lines of business and assists with department projects as needed.

Reports to: Director, Mgr, Appeals

Department: AZ-HS-Appeals

Position Location: Phoenix, AZ

Essential Functions:

  • Manages the Provider Dispute and Member Appeal Process from receipt to resolution.
  • Acts as the first point of contact in dealing with disputes and appeals.
  • Researches and documents supporting authority for decision using CMS, State Statute, Administrative Code, regulator policies and procedures and health plan guidelines
  • Logs, tracks, and processes health service appeals.
  • Serves as a liaison in corresponding and communicating with providers and members or members’ representatives as needed during appeal processing.
  • Interacts with other departments including Customer Service, Claims, Provider Relations and Pharmacy to resolve member and provider appeals and disputes.
  • Makes administrative dispute and appeal determinations when indicated and properly sets up case files for clinical review when needed.
  • Handles more complex/elevated cases and assists management with projects and audits.
  • Conducts dispute and appeal research and file processing including, but not limited to, requesting waivers of liability and/or appointment of representative forms, organizational determination research, requesting member medical records, organizing documentation, preparing written summaries, scheduling the case, processing the review of case, documentation of the appeal resolution and sending completed case files to external review organizations as required by regulatory guidelines.
  • Maintains all documentation associated with the processing and handling of appeals to comply with regulatory standards and timeframes while maintaining an accurate, complete appeals record in the electronic database.
  • Performs administrative activities including, but not limited to, generating, printing and mailing determination and authorization notification letters. Complete all associated data entry and authorization creation in WellCare systems. Correctly and completely prep completed case files for electronic storage.
  • Participates in cross-functional teams to address process improvement and claim dispute and appeal trends in order to positively impact receipts and provider and member satisfaction.
  • Assists in documenting processes and step actions.
  • Performs special projects as needed.
Additional Responsibilities:
    Candidate Education:
    • Required A High School or GED
    • Preferred An Associate's Degree in a related field
    Candidate Experience:
    • Required 3 years of experience in a claims, customer service, or health services environment
    • Preferred Other 1 year experience in claims disputes or appeals role
    Candidate Skills:
    • Intermediate Ability to effectively present information and respond to questions from peers and management
    • Intermediate Demonstrated written communication skills
    • Intermediate Knowledge of healthcare delivery
    • Intermediate Ability to effectively present information and respond to questions from families, members, and providers
    • Intermediate Ability to effectively present information and respond to questions from families, members, and providers
    • Intermediate Demonstrated interpersonal/verbal communication skills
    • Intermediate Demonstrated customer service skills
    Licenses and Certifications:
    A license in one of the following is required:
      Technical Skills:
      • Required Intermediate Microsoft Excel Working knowledge of Microsoft Office Products including Outlook, Word and Excel
      • Required Intermediate Microsoft Outlook Knowledge of or ability to learn and use personal computers and industry software including Peradigm, Sidewinder, and EMMA
      • Required Intermediate Microsoft Word
      • Required Intermediate Healthcare Management Systems (Generic)

        About us
        Headquartered in Tampa, Fla., WellCare Health Plans, Inc. (NYSE: WCG) focuses primarily on providing government-sponsored managed care services to families, children, seniors and individuals with complex medical needs primarily through Medicaid, Medicare Advantage and Medicare Prescription Drug Plans, as well as individuals in the Health Insurance Marketplace. WellCare serves approximately 5.5 million members nationwide as of September 30, 2018. WellCare is a Fortune 500 company that employs nearly 12,000 associates across the country and was ranked a "World's Most Admired Company" in 2018 by Fortune magazine. For more information about WellCare, please visit the company's website at EOE: All qualified applicants shall receive consideration for employment without regard to race, color, religion, creed, age, sex, pregnancy, veteran status, marital status, sexual orientation, gender identity or expression, national origin, ancestry, disability, genetic information, childbirth or related medical condition or other legally protected basis protected by applicable federal or state law except where a bona fide occupational qualification applies. Comprehensive Health Management, Inc. is an equal opportunity employer, M/F/D/V/SO.