Appeals Coordinator, Geisinger Health Plan (eastern standard time zone resident)

Job Duties

• Prepares and facilitates Member appeals, complaints and grievances by communicating directly with Members, their Representatives, Vendors and Medical Providers and their Representatives to obtain the necessary information to complete the appeal process successfully within the time period allowed by regulation.
• Investigates the full details of the appeal and complaints and grievances by consulting with, but not limited to, health care providers, legal services, internal medical staff and administration.
• Provides timely and accurate documentation of all communications with involved parties within both the individual case file and departmental tracking database.
• Ensures that all complaint, appeal and grievance time frames are met as dictated by guidelines set forth by the Department of Labor (DOL), the Department of Health (DOH), the Department of Insurance (DOI), the National Committee for Quality Assurance (NCQA), and the Centers for Medicare and Medicaid Services (CMS).
• Implements regulatory changes to current practices, policies and procedures within the Department.
• Maintains a complete and accurate database via departmental software for reporting and tracking and trending purposes.
• Covers regular audits of own files and data entry to ensure timely, accurate and appropriate documentation.
• Captures activities for review committees and educational sessions with other Health Plan departments to ensure overall compliance is maintained.
• Acts as the primary resource regarding the complaint, appeal and grievance processes to all other Health Plan and external entities, communicating with all entities involved throughout the appeals and grievance process.
• Maintains strict compliance with all applicable laws and regulations set forth by the Federal and State regulatory bodies, continually reviewing updates as pertains to regulatory changes and implement those changes within current departmental practices, policies and procedures.
• Makes suggestions for policies and procedures covering all regulatory and accreditation standards for all lines of business.

About the Role

Serves as a liaison between Members and the Plan with appeals regarding denied claims/services, referrals, membership and benefit issues and concerns regarding quality of care or service. Presents Member appeals to the Plan Medical Staff and Center for Medicare/Medicaid Services contracted reviewer.

Qualifications

Minimum of 5 years of relevant experience.

Skills

• Communication
• Working Independently
• Multitasking

Benefits

We offer healthcare benefits for full time and part time positions from day one, including vision, dental and prescription coverage.