The Provider Appeals Coordinator is responsible for managing the overall coordination, investigation, documentation and the resolution process of medical claims appeals and ensuring compliance with policies and procedures under BMCHP, MassHealth, Commonwealth Care contracts and NCQA standard guidelines.
KEY FUNCTIONS/RESPONSIBILITIES:
- The Appeals Coordinator is competent in the following related responsibilities but may not be expected to be responsible for all of the functions simultaneously. The Appeals Coordinator may have a major focus on administrative appeals; while also providing clinical edit claims review support to the dept Nurse Coordinator.
- Maintains the Provider Appeals process and workflow toward process improvement; provider satisfaction and claims payment accuracy under MassHealth, Commonwealth Care contract requirements and NCQA accreditation guidelines where applicable. Establish and ensures workflow continuity with the Plan in the areas of Claims Processing; Provider Servicing and Health Services.
- Responsible for the preparation and research of data and records required to assure timely processing of administrative appeals in compliance with BMCHP guidelines. Produces administrative appeals reports for management and nurse review, as well as ad hoc reports. Ensures the quality and organization of administrative appeal documentation.
- Provides claims review and interpretation of appropriateness of administrative appeal.
- Coordinates management of provider appeals with other departments and tracks through resolution.
- Ensures continuous improvement of the administrative appeals process and establishment of related workflows as needed in response to Plan policy and procedure or claims processing changes.
- Responds to, documents, investigates and facilitates the resolution of provider administrative appeals, including the writing, review, and approval of resolution letters.
- Identifies and communicates trends. Works with other departments to create and implement improvement plans.
QUALIFICATIONS:
EDUCATION:
- Bachelor’s degree in Health Care Administration, related field or, an equivalent combination of education, training and experience is required.
- Certification in Medical Coding (CPC Certification) preferred.
EXPERIENCE:
- 2 or more years experience working in a managed care organization required.
- Experience with claims processing and appeals required.
- Knowledge of Medical Coding, Medical terminology, CPT‚ ICD9‚ and HCPCS codes required.
- Project Management experience highly desirable.
COMPETENCIES, SKILLS, AND ATTRIBUTES:
- Demonstrated ability to successfully plan, organize and manage projects within a managed care organization.
- Strong working knowledge of Microsoft Office products required.
- Detail oriented, excellent verbal and written communication skills essential. Ability to work in both team and independent settings at all levels of the organization.
- Good customer service skills essential. Experience working with diverse populations preferred. Knowledge of health care terminology helpful.
- Effective collaborative and proven process improvement skills.
- Strong oral and written communication skills; ability to interact within all levels of the organization.
- A strong working knowledge of Microsoft Office products.
- Demonstrated ability to successfully plan, organize and manage projects.
- Detail oriented, excellent proof reading and editing skills.
WORKING CONDITIONS AND PHYSICAL EFFORT:
- Ability to work OT during peak periods.
*Qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, disability or protected veteran status.
Required Skills
Required Experience