This position is forCare1st Health Plan, a WellCare Healthplans, Inc. company.
Processes appeals from receipt to resolution in a timely and accurate manner. Frequently serves as departmental subject matter expert by training and answering questions for less experienced staff. Handles complex cases and assists with departmental projects as needed.
Report to: Claims and Appeals Manager
Location: Phoenix, AZ.
Job Type: Hourly/Non-Exempt
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.
- Provides guidance and training to less experienced staff on policy, procedure and best practice.
- Handles more complex/elevated cases and assists management with projects and audits.
- Conducts general 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 scanning and archiving.
- Develops and presents ideas for performance and process management improvement within the department. Notify Supervisor or other appropriate parties of identified patterns of appeals, claim errors, configuration issues, or other systemic problems identified during appeal processing.
- Assists in documenting processes and step actions.
- Fills in for supervisor when needed.
- Performs special projects as needed.
Education: A High School Diploma required. An Associate's Degree preferred.
Experience: 3 years practical work experience in a claims, customer service, or health services environment. Minimum 9 months experience as an Appeals Coordinator.
Special Skills (e.g. 2nd language):
Senior Appeals Coordinators are expected to have the ability to effectively communicate in the form of presenting information, responding to questions from clinical and non-clinical Appeals staff, other WellCare departments, WellCare providers, and members. You must have the ability to write concise, grammatically correct notes and business correspondence, 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 or ability to learn and use personal computers and industry software including Peradigm, Sidewinder, and EMMA