Healthcare Appeals Coordinator

  • location: Tampa, FL
  • type: Contract
  • salary: $16.50 per hour
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job description

Healthcare Appeals Coordinator

job summary:
Day to Day Responsibilities of this Position and Description of Project:

Analyze and resolve verbal and written claims and authorization appeals from providers and pursue resolution of formal grievances from members.Job Responsibilities: Gather, analyze and report verbal and written member and provider complaints, grievances and appeals Prepare response letters for member and provider complaints, grievances and appeals Maintain files on individual appeals and grievances May coordinate the Grievance and Appeals Committee Support the pay-for-performance programs, including data entry, tracking, organizing, and researching information Assist with HEDIS production functions including data entry, calls to provider's offices, and claims research. Manage large volumes of documents including copying, faxing and scanning incoming mail

Education/Experience: High school diploma or equivalent. Associate's degree preferred.2-4 years of experience

JOB SUMMARY

Research and resolve all escalations from members/providers that have been addressed to Client's Executive Offices,

Executive Leadership Team or the CEO (Presidential) as well as complaints coming from other escalated areas such as MET,

Grievances, and other areas for final resolution. The Service Escalation Unit (SEU) team is the highest level of escalation and

handles issues for all lines of business (Medicare, Medicaid, PDP & Exchange).

Key Duties and Responsibilities

Resolve the most highly escalated issues coming from other escalated areas such as MET, Grievances, and other areas for final resolution. The SEU team is the highest level of escalation.

Take escalated inbound/outbound phone calls on behalf of our Executive Leadership Team for all lines of business while maintaining the highest standard of quality on every call. (Calls are monitored for Quality and Training purposes.)

Logs, tracks, resolves and responds to all assigned inquires and complaints from members, providers, governing bodies,Regulatory Agencies, Better Business Bureau, Social Media, Client Legal Department, Corporate Compliance TRUST Department, Agency for Healthcare Administration (AHCA) and Florida Healthy Kids in writing and/or by telephone, while meeting all regulatory, AHCA and Client Corporate guidelines in which special care is required to enhance Client's

relationships; while meeting and exceeding all performance standards.

Subject Matter Expert in all lines of business.

Effectively handle/resolve highly escalated issues and represent our CEO in responding to these complaints in a professional

manner seeking a win/win for all parties while respecting sound business and health management practices.

Assist in the education of new members and in the re-education of existing members regarding health plan procedures.

Thoroughly research and effectively communicate with our members regarding the resolution of their inquiries, complaints

and issues with a professional demeanor in a clear, articulate, and timely manner while demonstrating a strong understanding of the issues.

Work with providers to correct billing and claim issues and educate providers about how to eliminate those problems going forward.

Act as a liaison between internal departments and external partners on data gathering and problem solving while

investigating problems of an unusual nature in the area of responsibility. Present proposed solutions in a clear and concise manner.

Identify trends and monitor the root cause of member/provider issues and work cross functionally with different departments to ensure enterprise wide solutions.

Perform other duties as assigned.

 
location: Tampa, Florida
job type: Contract
work hours: 8 to 5
education: High School
experience: 2 Years
 
responsibilities:
Key Duties and Responsibilities

Resolve the most highly escalated issues coming from other escalated areas such as MET, Grievances, and other areas for final resolution. The SEU team is the highest level of escalation.

Take escalated inbound/outbound phone calls on behalf of our Executive Leadership Team for all lines of business while maintaining the highest standard of quality on every call. (Calls are monitored for Quality and Training purposes.)

Logs, tracks, resolves and responds to all assigned inquires and complaints from members, providers, governing bodies,Regulatory Agencies, Better Business Bureau, Social Media, Client Legal Department, Corporate Compliance TRUST Department, Agency for Healthcare Administration (AHCA) and Florida Healthy Kids in writing and/or by telephone, while meeting all regulatory, AHCA and Client Corporate guidelines in which special care is required to enhance Client's

relationships; while meeting and exceeding all performance standards.

Subject Matter Expert in all lines of business.

Effectively handle/resolve highly escalated issues and represent our CEO in responding to these complaints in a professional

manner seeking a win/win for all parties while respecting sound business and health management practices.

Assist in the education of new members and in the re-education of existing members regarding health plan procedures.

Thoroughly research and effectively communicate with our members regarding the resolution of their inquiries, complaints

and issues with a professional demeanor in a clear, articulate, and timely manner while demonstrating a strong understanding of the issues.

Work with providers to correct billing and claim issues and educate providers about how to eliminate those problems going forward.

Act as a liaison between internal departments and external partners on data gathering and problem solving while

investigating problems of an unusual nature in the area of responsibility. Present proposed solutions in a clear and concise manner.

Identify trends and monitor the root cause of member/provider issues and work cross functionally with different departments to ensure enterprise wide solutions.

Perform other duties as assigned.





Internal/External Groups with which the Candidate will interface:





















Preferred Skills:





















Customer Service/Healthcare Experience - 3 yrs





1.





Spanish language















Written/Verbal Communication - Advanced level





2.





Self-motivation















Analytical skills - Advanced level





3.





















Time Management/Prioritizing Skills - Advanced level





4.





















Experience in handling escalations/complaints





5.

















 
qualifications:
Education/Experience: High school diploma or equivalent. Associate's degree preferred.2-4 years of experience

 
skills: Human Resources
Equal Opportunity Employer: Race, Color, Religion, Sex, Sexual Orientation, Gender Identity, National Origin, Age, Genetic Information, Disability, Protected Veteran Status, or any other legally protected group status.

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