Responsible for Oversight of that that investigates and resolution of appeals scenarios for all products
Ensure timely, customer focused response to appeals
Identify trends and emerging issues and report and recommend solutions
Independently coaches others on appeals ensuring compliance with Federal and/or State regulations
Manage control and trend inventory, independently investigate, adapts to changes or revise policy to resolve the most escalated cases
Responsible for serving as the point of contact for the appeal if there is an inquiry from leadership, compliance and State regulators
Understand and adapt to departmental process and policies
Research incoming electronic appeals, complaints and grievance to identify if appropriate for unit based upon published business responsibilities

At least 2+ years in one of the following areas: claim platforms, products, and benefits; patient management; product or contract drafting; compliance and regulatory analysis; special investigations; provider relations; customer service or audit experience
Some Medicare and/or Medicaid knowledge
Experience in reading or researching benefit language
Ability to work in fast paced, high volume environment
Excellent organizational skills to handle high inventory which aids in meeting or exceeding metrics
Solution driven and can handle complex issues with accuracy

Senior Coordinator, Complaint & Appeals

Key skills