Phoenix, United States
about 1 year ago
Onsite role - No remote work.
Updates appeals tracking system, consults with Appeals Analyst Specialist regarding technical claims issues; determines required expert resources at each juncture and solicits input. Based on appeal investigation, determines whether claim is reopened or original denial was appropriate. Proactively communicated with appellants, leadership team, providers and the original case manager to resolve investigation issues, resolve issues and communicate decisions/rationale for denial/approval.
Responsibilities include: timely completion of appeals investigation, fairness of administrative decisions, timely notification and development of case summary to include IRE packet development Requires the ability to consistently apply appropriate administrative and regulatory criteria for reviewing and making decisions on all non-clinical appeals and validating the accuracy of all received information Requires the ability to consistently apply appropriate administrative and regulatory criteria
Requires effective communication abilities (written and verbal) when documenting actions and communications with Members, Providers, Medical Director and appeals leadership. The role works closely with the multiple other roles and requires the ability to communicate status variances This role serves as a communication bridge between the appeals department and the claims department
Responsible for maintaining and prioritizing work load to support appeal timeliness and communicate risks, concerns or opportunities to leadership related to their work load.