Responsible for managing to resolution appeal scenarios for all products
Develop into a subject matter expert by providing training, coaching, or responding to complex issues
Research and resolves incoming electronic appeals as appropriate as a “single-point-of-contact” based on type of appeal
Can identify and reroute inappropriate work items that do not meet complaint/appeal criteria
Assemble all data used in making denial determinations
Research standard plan design, certification of coverage and potential contractual deviations
Review a clinical determination and understand rationale for decision
Coordinates efforts both internally and across departments to successfully resolve claims research

1-2 years Medicare part C Appeals experience
Experience in reading or researching benefit language in SPDs or COCs
Experience in research and analysis of claim processing a plus
Demonstrated ability to handle multiple assignments competently, accurately and efficiently
Excellent verbal and written communication skills
Excellent customer service skills
Experience documenting workflows and reengineering efforts

Affordable medical plan options
401(k) plan (including matching company contributions)
Employee stock purchase plan
No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs
Confidential counseling and financial coaching
Paid time off
Flexible work schedules
Family leave
Dependent care resources
Colleague assistance programs
Tuition assistance
Retiree medical access

Senior Coordinator, Complaint Appeals Operations

Key skills