Processes appeals from receipt to resolution in a timely and accurate manner.
- 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.
- Makes administrative appeal determinations when indicated and properly sets up case files for clinical review when needed.
- Conducts general appeal research and filing 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. Completes all associated data entry and authorization creations in WellCare systems. Correctly and completely preps completed case files for scanning and archiving.
- Develops and presents ideas for performance and process management improvement within the department. Notifies Supervisor or other appropriate parties of identified patterns of appeals, claim errors, configuration issues, or other systemic problems identified during appeal processing.
- Performs special projects as needed.
Education: A High School Diploma required. A Associate's Degree preferred.
Experience: 1-2 years practical work experience in a claims, customer service, or health services environment. Previous experience in appeals and/or grievances is preferred.
Special Skills (e.g. 2nd language):
Ability to effectively communicate, present information and respond to questions from clinical and non-clinical Appeals staff, other WellCare departments, WellCare providers and members. Ability to write concise, grammatically correct notes and business correspondence. Ability to review correspondence and system data to establish facts and draw valid conclusions consistent with applicable policy and procedures with minimal supervision.
Technical Skills/Requirements: Working knowledge of Microsoft Office Products including Outlook, Word and Excel. Knowledge of and/or ability to learn and use personal computers and industry software such as Peradigm, Sidewinder, and EMMA.