Job Description

At Brighton Health Plan Solutions (BHPS), we’re creating something new and different in health care, and we’d love for you to be part of it.  Based in New York City, BHPS is a rapidly growing, entrepreneurial health care enablement company bringing tangible innovation to the health care delivery system.  Under the Brighton Health Group portfolio with the support of a premier investor group led by Goldman Sachs, our 250-person team is committed to transforming how health care is accessed and delivered. We believe that cost, quality, and population health are optimized when people have long term relationships with their health care providers – and that’s why we’re creating new products that today do not exist anywhere in the New York/New Jersey market. With a growing labor business under the well-known MagnaCare brand, the launch of Create - a new marketplace of health systems focused on self-insured commercial health plan sponsors, and a successful Casualty business, we’re fiercely committed to positively impacting our partners. 

COMPANY MISSION:

Transform the health plan experience – how health care is accessed and delivered – by bringing outstanding products and services to our partners.

COMPANY VISION: 

Redefine health care quality and value by aligning the incentives of our partners in powerful and unique ways.  

ABOUT THIS ROLE:

BHPS is seeking an experienced Appeals Coordinator skilled in investigating and resolving grievances, provider payment disputes and medical appeals submitted by our members and providers. Responsible for ensuring all determination responses are compliant with all established regulations.

PRIMARY RESPONSIBILITIES:

• Thorough review of claims and medical documentation

• Prepare cases for clinical review 

• Advanced claim processing including professional, facility and ancillary claims

• Provide accurate and timely responses to appeals, grievances and all other correspondence

• Communicate effectively with individuals/teams to ensure high quality and timely expedition of customer requests

• Research and document pertinent information on claims requiring adjudication

• Apply medical policy, contractual provisions and operational procedures to ensure accurate adjudication, adjustment or determination response

• Assist Customer Service in responding to and resolving customer questions and concerns related to correspondence

• Contribute ideas on ways to resolve problems to better serve the customer and/or improve productivity

• Solve problems that are sometimes unstructured and that may require reliance on conceptual thinking

• Maintain broad knowledge of client products and services

ESSENTIAL QUALIFICATIONS:

• Strong knowledge of contracts, medical terminology, and claims processing and procedures

• 1+ year computer medical billing or claims adjudication systems experience

• Previous experience handling appeals and grievances

• Excellent written and oral communication, interpersonal and negotiation skills with a demonstrated ability to prioritize tasks as required

• Ability to meet expected production standards

• Proficient in Microsoft Office Suite- specifically Microsoft Word and Microsoft Excel

• Ability to maintain a professional demeanor under pressure 

• Capable of managing multiple complex issues 

• Strong knowledge of contracts, medical terminology, and claims processing and procedures

• High School Diploma or GED diploma; some college or business school education is a plus

*WE ARE AN EQUAL OPPORTUNITY EMPLOYER

Company Description

Brighton Health Plan Solutions Company Mission: Transform the health plan experience – how health care is accessed and delivered – by bringing outstanding products and services to our partners Company Vision: Redefine health care quality and value by aligning the incentives of our partners in powerful and unique ways