Appeals Coordinator II

Summary

MedReview Inc. provides payment integrity solutions for healthcare, including DRG validation, cost outlier, and readmission reviews. The Appeals Coordinator II supports Appeals Department leadership by researching, investigating, analyzing, tracking, and resolving nonclinical appeals, grievances, complaints, and provider inquiries in a timely and compliant manner.

Responsibilities

• Prepare and disseminate case file for External Reviews and/or State Fair Hearing
• Manage and monitor all appeals from Non-Participating providers
• Independently prepare well written, customized responses to all provider inquiries/complaints that appropriately and completely address the complainant’s issues and are structurally accurate
• Ensure timely review, research, and resolution of appeals, grievances, and complaints within guidelines. Ensures that all complaints are handled and resolved in compliance with timeliness requirements, and at the highest standards for accuracy
• Consults with managers on problem cases and interfaces with clinical supervisors, account managers, and other personnel in resolving health plan requests or provider inquiries
• Log and track grievances, appeals, and other types of complaints as needed
• Review and determine outcome of appeal/grievance, either independently or in conjunction with clinical appeal staff
• Consults with subject matter experts and resources available within organization to assist in appeal and complaint resolution
• Make critical decisions regarding research and investigation to appropriately resolve all inquiries
• Serve as a liaison to Appeal Coordinator providing guidance and expertise to ensure timely resolution of cases
• Other duties and responsibilities as assigned

Skills

• Associates Degree. Additional years of related experience may be used in place of education requirements
• 3+ years' experience working in the health care industry
• Experience in DRG Pricing using WebStrat
• Knowledge in claim payment methodology
• Good MS Office skills. Particularly Excel
• Excellent problem solving and analytical skills required
• Ability to manage priorities in a complex environment
• Excellent organization and time management skills required
• Excellent written and verbal communication skills
• Takes initiative to proactively identify and solve problems
• Ability to meet strict, time sensitive deadlines
• Ability to cope well with ambiguity and stressful situations
• Must show patience and the ability to remain calm under pressure in an atmosphere of frequent interruptions
• High speed internet (100 Mbps per person recommended) with secured WIFI
• A dedicated workspace with minimal interruptions to protect PHI and HIPAA information
• Must be able to sit and use a computer keyboard for extended periods of time
• Experience in inpatient claims, DRG and High-Cost Outlier claims preferred

Qualifications

Must Haves

• Associates Degree. Additional years of related experience may be used in place of education requirements
• 3+ years' experience working in the health care industry
• Experience in DRG Pricing using WebStrat
• Knowledge in claim payment methodology
• Good MS Office skills. Particularly Excel
• Excellent problem solving and analytical skills required
• Ability to manage priorities in a complex environment
• Excellent organization and time management skills required
• Excellent written and verbal communication skills
• Takes initiative to proactively identify and solve problems
• Ability to meet strict, time sensitive deadlines
• Ability to cope well with ambiguity and stressful situations
• Must show patience and the ability to remain calm under pressure in an atmosphere of frequent interruptions
• High speed internet (100 Mbps per person recommended) with secured WIFI
• A dedicated workspace with minimal interruptions to protect PHI and HIPAA information
• Must be able to sit and use a computer keyboard for extended periods of time

Nice to Haves

• Experience in inpatient claims, DRG and High-Cost Outlier claims preferred

Benefits

• Remote work