Appeals Coordinator Resume Samples

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D Reilly

Dan

Reilly

314 Pouros Flats

Philadelphia

+1 (555) 841 9444

314 Pouros Flats

Philadelphia

Phone

p +1 (555) 841 9444

Experience Experience

Houston, TX

Appeals Coordinator

Houston, TX

Bogisich LLC

Houston, TX

Appeals Coordinator

Provide input to management regarding current inventory issues for inquiry analysis
Review and apply new and updated procedures and guidelines. Identify quality-related problems and recommend process improvements
Use of two-way communication process as a standard practice. Works to reduce communication barriers that inhibit productivity
Working knowledge Microsoft Product Suite
Perform additional job-related duties as assigned
Under the direction of Appeals management
CMC contact for other areas involved in processing appeals and member complaints

San Francisco, CA

Grievance & Appeals Coordinator

San Francisco, CA

Gaylord, Gleichner and Hegmann

San Francisco, CA

Grievance & Appeals Coordinator

Assist member or provider, or provider on behalf of the member, in filing a formal appeal and grievance
Provides superior customer service to clients, members, providers, facilities etc
Uses critical thinking and knowledge of NEMT to develop action plans in conjunction with Quality Assurance Supervisor
Coordinates and handles all member and provider appeals and grievances, including the member grievances, appeals, requests and disputes
Researches and resolves complaints in collaboration with the Quality Assurance Supervisor and General Manager
Identifies deficiencies and develop corrective action plan to ensure compliance is met
Receives customer (clients, providers, facilities, etc.) grievances and grievances and documents each contact in the system

present

Philadelphia, PA

Grievances / Appeals Coordinator

Philadelphia, PA

Hackett, Roob and Feeney

present

Philadelphia, PA

Grievances / Appeals Coordinator

present

Provides written and verbal education and training to staff, providers, and members
Complete projects and other research tasks as assigned by area management
Manage the receipt, investigation and resolution of standard complaint and appeal issues in a timely and highly effective manner
Receipt and processing of all incoming mail for Appeals Department
Maintain knowledge of all system, contractual, compliance standard changes and policy updates, and attend additional training sessions as necessary
Generates all reports related to the appeals process
The Appeals Coordinator is responsible for the processing of all administrative appeals and presenting to the Administrative Appeal Committee for resolution

Education Education

Associate’s Degree in Related Field

Georgia State University

Associate’s Degree in Related Field

Skills Skills

Ability to effectively communicate, present information and respond to questions from clinical and non-clinical Appeals staff, other WellCare departments, WellCare providers and members
Demonstrates knowledge of and ability to research and look up on SMS vaious codes: revenue, service, diagnosis, procedure (CPT4 and ICD9) and HCPS
Ability to review correspondence and system data to establish facts and draw valid conclusions consistent with applicable policy and procedures with minimal supervision
Knowledge of and/or ability to learn and use personal computers and industry software such as Peradigm, Sidewinder, and EMMA
Knowledge of and/or ability to learn and use computers and industry software such as Peradigm, Sidewinder, and EMMA
Ability to effectively communicate, present information and respond to questions from clinical and non-clinical appeals staff, other WellCare departments, WellCare providers and members
Ability to interact effectively and professionally with all levels of management as well as internal and external customers
Strong organizational, analytical and problem solving skills
Excellent written and verbal communication skills
Ability to work in a fast-paced environment and manage time sensitive task completion on a daily basis

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8 Appeals Coordinator resume templates

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Appeals Coordinator Resume Examples & Samples

At least 5 years of medical case management or claims administration experience in a program/policy or administration role
College or professional certification/credential in the area of leave, insurance or disability administration desired (CDMS, CRC, CCM, etc.)
Mental Health experience preferred
Strong organizational skills/detail oriented
Respect for confidentiality of information
Strong PC skills including Microsoft Office suite of programs including not limited to Excel, PowerPoint, Word, etc
Intermediate understanding of disability processes
Experience using a claim or leave administration system

Appeals Coordinator Resume Examples & Samples

Logs, tracks, and processes health service appeals
Serves as a liaison in corresponding and communicating with providers and members or members’ representatives as needed during appeal processing
Interacts with other departments including Customer Service, Claims, Provider Relations and Pharmacy to resolve member and provider appeals
Makes administrative appeal determinations when indicated and properly sets up case files for clinical review when needed
Conducts general appeal research and filing including, but not limited to, requesting waivers of liability and/or appointment of representative forms, organizational determination research, requesting member medical records, organizing documentation, preparing written summaries, scheduling the case, processing the review of case, documentation of the appeal resolution and sending completed case files to external review organizations as required by regulatory guidelines
Maintains all documentation associated with the processing and handling of appeals to comply with regulatory standards and timeframes while maintaining an accurate, complete appeals record in the electronic database
Performs administrative activities including, but not limited to, generating, printing and mailing determination and authorization notification letters
Completes all associated data entry and authorization creations in WellCare systems. Correctly and completely preps completed case files for scanning and archiving
Develops and presents ideas for performance and process management improvement within the department. Notifies Supervisor or other appropriate parties of identified patterns of appeals, claim errors, configuration issues, or other systemic problems identified during appeal processing
Performs special projects as needed
1-2 years practical work experience in a claims, customer service, or health services environment is required
Previous experience in appeals and/or grievances is preferred
Ability to effectively communicate, present information and respond to questions from clinical and non-clinical Appeals staff, other WellCare departments, WellCare providers and members
Ability to review correspondence and system data to establish facts and draw valid conclusions consistent with applicable policy and procedures with minimal supervision
Working knowledge of Microsoft Office Products including MS Outlook, MS Word and MS Excel is required

Expedited Appeals Coordinator Resume Examples & Samples

Provide expertise or general claims support by reviewing, researching, investigating, negotiating and resolving all types of appeals and grievances
Analyze and identify trends and provides reports as necessary
Extensive work experience within own function
May act as a resource for others
*This is a Tuesday - Saturday opening in which the working hours are Tuesday - Friday from 11:30am - 8pm and 9am - 5:30pm on Saturday
Experience with document creation and modification with MS Word
Experience performing data entry within MS Excel
1+ year of prior authorization experience (i.e. someone who possesses claims background and has worked with claims within an insurance company/medical group)
1+ year of Appeals and grievances experience (i.e. understand the differences between an appeals and grievances, someone who has worked for a medical group or within a medical type environment)

Senior Grievance & Appeals Coordinator Resume Examples & Samples

Ensures the company is compliant with the federal regulations
Ensures that the rights of appealing parties are protected in all instances where claim and authorization activities result in a less that favorable determination
Provides training and daily support of the staff processing appeals; auditing and quality control of appeals cases
Provides assistance to customers for complex and unique issues related to appeals
Processes complex appeal cases
Liaisons between Health Net and external parties to provide support throughout all levels of the appeal process
Interacts with other departments to ensure compliance with federal requirements as they relate to the area of appeals
Assists in the establishment of Appeals Policy and Procedures; Audit claim and authorization appeals for compliance with policies and procedures and other applicable guidelines. Reports audit findings and recommends process improvements and corrective action plans based on audit results and trend analysis
Analyzes and identifies impact of change orders on appeals operations
Prepares reports and performs trend analysis
Three to five years claims processing and/or medical management experience required
Any combination of academic education, professional training or work experience, which demonstrates the ability to perform the duties of the position
Ability to comprehend and interpret policies and Federal Regulations
CPT/HCPC/ICD-9 coding abilities

Appeals Coordinator Resume Examples & Samples

Responsible for logging, tracking and responding to all member and/or provider appeals of adverse determinations related to medical necessity as well as administrative determinations
Handle all appeals promptly and efficiently in compliance with URAC, NCQA and DOL
Accurately process all appeal requests for New Jersey members (wherever service is provided) in all applicable lines of business and all covered services, including Magellan Behavioral Health, as appropriate
Maintain solid understanding of regulatory requirements, benefit structures and contracts with the ability to assume decision making responsibility as appropriate
Coordination of all internal appeals processes as necessary
Maintain complete appeal files and complete statistical information for reporting purposes
Responsible for sending written acknowledgement of appeal request as well as appeal response letter member and/or provider on behalf of member, as appropriate
Responsible for collecting all information from appropriate area and preparing the file for medical review by the Medical Director and appeals panel
Responsible for keeping all parties apprised of the status and result of appeal
Responsible for coordinating and administrating requests for IRO reviews, as per state regulatory requirements
CMC contact for other areas involved in processing appeals and member complaints
Use of two-way communication process as a standard practice. Works to reduce communication barriers that inhibit productivity
Seeks team or mutual approaches to opportunities and problems and evaluates decisions based on their impact on others
Perform additional job-related duties as assigned
Four to six years experience as an appeals specialist in an MCO appeals department with a minimum of two years processing experience in COS, SLIQ, CMS, MAS, MSIQ
Knowledge of current state, federal legislation and accrediting body standards governing the processing of member appeals
Knowledge of appropriate health insurance benefits application, contracts and NJ commercial appeals processes
High motivation and the ability to work independently
Ability to work in a fast-paced environment and manage time sensitive task completion on a daily basis
Ability to prioritize appropriately, and manage multiple tasks and job responsibilities
Ability to interact effectively and professionally with all levels of management as well as internal and external customers
Proficiency in utilizing Microsoft Word, Excel and Access programs
Knowledge of corporate and HIPAA confidentiality requirements/standards

Ssc-denials & Appeals Coordinator Resume Examples & Samples

Monitor Advanced Beneficiary Notices and denials as it relates to medical necessity requirements
Identify and evaluate denials to determine specific issues and patterns that need to be addressed with the facility
Investigate all payer denials and take appropriate action including but not limited to appeals, corrected billing and chart reviews
Document patient accounting system with all denial activity and actions taken
Compile monthly denial reports
Maintain all data elements related to denials in the Compliance 360 module
High School graduate minimum requirement
Minimum 3-5 years’ experience in a hospital business office department
Strong analytical skills and strong proficiency in Microsoft Office Tools

Audit & Appeals Coordinator Resume Examples & Samples

Handles incoming mail in a manner which recognizes the importance, confidentiality, and time-sensitivity of mail; ensures mail is sorted and date stamped as soon as possible after it arrives; and files, scans, copies, and/or enters into audit/appeals tracking and performance software program, as appropriate
Works in partnership with the RN Audit & Denial Care Managers in various facets and through different stages of processes and procedures
Analyzes and coordinates workflow within the department, tracking all government and commercial insurance correspondence from initial medical record requests, to findings, and on through the appeals process
Ensures that each step of the process is documented and performed within the required timeframes
Reviews and analyzes all findings for recoupments and denials, coordinating with the PFS Department, when necessary
Works closely with the organization’s third-party physician advisor in requesting clinical justification letters for retrospective, medical necessity and coding appeals
Coordinates information flow of appeal data through our tracking software program, or through other means, to third-party general counsel
Analyzes output from tracking software to assure that all items are accounted for and timelines are met
Directs submission of requested medical record information through third-party ROI vendor or PFS, depending on type of audit request
Offers process improvement considerations as well as options in the software tools
Previous experience in a healthcare or other office setting

Grievances / Appeals Coordinator Resume Examples & Samples

Develop and implement the necessary processes to manage the receipt, investigation and resolution of administrative complaints, grievances and appeals within the quality standards and timeframes required
Maintain a current knowledge of plan products, policies and procedures with the ability to relate this information in a clear, concise and understandable manner to member, providers, and other customers, both internal and external
Manage the receipt, investigation and resolution of standard complaint and appeal issues in a timely and highly effective manner
Interface with the appropriate Beacon Health Options management and staff at all levels to present and summarize Complaint and Appeal cases
Maintain knowledge of all system, contractual, compliance standard changes and policy updates, and attend additional training sessions as necessary
Comply with all HIPAA Compliance regulations

Appeals Coordinator Resume Examples & Samples

Logs, tracks, and processes health service appeals, complaints & grievances (ACG)
Serves as a liaison in corresponding and communicating with providers and members or members’ representatives as needed during AC&G processing
Conducts general AC&G research and filing including, but not limited to, requesting waivers of liability and/or appointment of representative forms, organizational determination research, requesting member medical records, organizing documentation, preparing written summaries, scheduling the case, processing the review of case, documentation of the AC&G resolution and sending completed case files to external review organizations as required by regulatory guidelines
Maintains all documentation associated with the processing and handling of AC&G to comply with regulatory standards and timeframes while maintaining an accurate, complete appeals record in the electronic database
Develops and presents ideas for performance and process management improvement within the department. Notifies Supervisor or other appropriate parties of identified patterns of appeals, claim errors, configuration issues, or other systemic problems identified during AC&G processing
Minimum 1-2 years practical work experience in a claims, customer service, or health services environment
Ability to effectively communicate, present information and respond to questions from clinical and non-clinical appeals staff, other WellCare departments, WellCare providers and members
Knowledge of and/or ability to learn and use computers and industry software such as Peradigm, Sidewinder, and EMMA

Appeals Coordinator Resume Examples & Samples

Coordinates the clinical appeal process through the collection of clinical records and consultation with Physician Advisors/Medical Director and communicates final determination
Experience working in a contact center environment
Ability to talk on the telephone and type on a computer simultaneously

Claims Audit & Appeals Coordinator Resume Examples & Samples

Handles written response to incoming reconsideration requests from providers and outside agencies
Enters provider demographic and contract affiliation information into the health plan system
Researches and documents inquiries and proactive research in a thorough, professional and expedient manner
Completes appropriate documentation for tracking/trending data
Composes correspondence to reflect accurate resolution information in a clear, concise, grammatically correct format
Maintains tracking system of correspondence and outcomes of request; maintain organized and accurate files
Monitors each request to ensure all internal and regulatory timelines are met
Communicates with Provider Service Representatives regarding relevant provider issues
Trains other representatives in the department
Serves as liaison with other cross-departmental projects with Provider Services and Member Services
Serves as project leads on specific, complex, multi-dimensional projects assigned by Director of Provider Inquiry R&R
Comprehensive knowledge of healthcare customer service
Good MS Office knowledge (Outlook, Word, and Excel)
Ability to type 40 WPM
Ability to work in multi-disciplinary teams and the ability to perform independently while handling multiple projects simultaneously
3 years experience in a managed care setting
4+ years of experience

Appeals Coordinator Resume Examples & Samples

Maintains a caseload and monitors day to day compliance of appeal decision time frames
Coordinates and distributes first, second and third level appeal request assignments
Consults with managers on problem cases and interfaces with case managers, clinical supervisors, account managers and other personnel in resolving denial and appeal questions
Responds to member, provider, and client telephone inquiries regarding status, process and outcome of appeals

Grievance & Appeals Coordinator Resume Examples & Samples

Screen all incoming grievances, appeals and provider claim dispute to ensure they are in compliance with CMS guidelines and the corporation’s policies
Gather, analyze and report verbal and written member and provider complaints, grievances and appeals
Prepare response letters for member and provider complaints, grievances and appeals
Conduct grievance and appeal investigations and provider claim dispute investigations through internal and external interviews, chart and contract audits, inspection, and interpretations of appropriate CMS guidance and policies
Maintain files on individual appeals and grievance cases
Manage the corporation’s grievance and appeals database
Coordinate with all relevant departments to streamline the appeals and grievance processes
Help prepare cases for Medicare Appeals Committee (MAC) review
Identify training, process improvement and other ways to maximize team performance and recommend action plans to management
Associate’s degree in health care administration, social work, related field or equivalent experience
1+ years of social work community relations or grievance and appeals experience, preferably in a managed care environment
Previous call center/customer service experience; claim experience; Part D experience, appeals and grievance experience, critical thinking skills

Senior Appeals Coordinator Resume Examples & Samples

Responsible for preparation of written detailed case history and presentation of second level appeal cases to the Appeals Panel for final company determination
Responsible for maintaining the integrity of the company relationship with customers by researching, resolving and responding to customer inquiries for appeals, disputes and scheduling issues
Responsible for identifying risk situations, consulting with senior management staff and rendering determinations that could adversely affect the company
2+ years customer service
2+ years behavioral health
2+ years healthcare claims
2+ years experience in processing appeals and/or claims

Appeals Coordinator Resume Examples & Samples

Under the direction of Appeals management
Experience in mental health or medical records preferred
Organizational and time management skills are also required

Appeals Coordinator Resume Examples & Samples

Familiar with and can assist in coordinating peer review scheduling involving internal Physician Advisors and external vendors
Documents process and findings within the Appeals and the Complaint databases, and internal systems
Assists in developing workflows and innovative process improvements to positively impact the department overall

Appeals Coordinator Resume Examples & Samples

Research and determine validity of inquiries identified as appeals received from members. Review additional documentation to determine if information needs to be forwarded to a clinician for additional consideration
Render an independent decision based on research of the initial claim processing activity, documented procedures and policies, and information supplied with the appeal request
Respond timely to inquiries that constitute an appeal or reopening of an initial claim determination, including generating written correspondence to the inquirer and other parties to the appeal
Ensure members’ appeal right are upheld and the corporate is in compliance with government guidelines
Identify errors made during claims processing and follow procedures to initiate referrals and forward requests to appropriate units as necessary. Resolve adjustment claims which suspended
Provide input to management regarding current inventory issues for inquiry analysis
Review and apply new and updated procedures and guidelines. Identify quality-related problems and recommend process improvements
Ability to make independent decisions relating to claims processing accuracy
Sound research and decision making to respond to inquiries
Thorough knowledge of claims policies and benefits, processing instructions, as well as medical terminology
Knowledge of processing systems

Grievance & Appeals Coordinator Resume Examples & Samples

Receives customer (clients, providers, facilities, etc.) grievances and grievances and documents each contact in the system
Researches and resolves complaints in collaboration with the Quality Assurance Supervisor and General Manager
Provides grammatically correct, well-written, and appropriate responses to grievances
Uses critical thinking and knowledge of NEMT to develop action plans in conjunction with Quality Assurance Supervisor
Ensures all customers receive accurate service information. Maintains appropriate correspondence with complainant from receipt of complaint to resolution
Produces complaint reports, summaries, and program reports/letters
Monitors and scores customer service representative calls
Provides superior customer service to clients, members, providers, facilities etc
Manages information regarding specific eligibility requirements for all programs within the Medical Transportation Program
3 years minimum in customer service, quality assurances, or investigative environment
Grievance experience strongly preferred
Must type a minimum of 45 words/minute General computer and software experience (word processing, data base software and spreadsheet.)
Critical thinking and problem resolution skills
Must be able to work independently in a fast-paced/multi-tasked environment and understand the concept of customer service and success

Appeals Coordinator Resume Examples & Samples

Demonstrates medical terminolgy knowledge and proper procedures in verifying charges on bills are accurate
Demonstrates knowledge of and ability to research and look up on SMS vaious codes: revenue, service, diagnosis, procedure (CPT4 and ICD9) and HCPS
Reviews and changes room and board charges as appropriate
States the correct write-off policy and demonstrates proper account processing for handling denials
Processes technical appeals by writing letter of appeal with supporting documentation. Uses payor-specific requirements to support appeal
States rebill policy and demonstrate proper procedure for requesting rebills and completing rebill request forms
College education of 60 semester hours , of which 30 must be in business-related courses. This requirement can be satisfied by extensive Hospital Business Office or third party experience- minimum of 5 years
Excellent computer skills with spreadsheet and word processing experience necessary
Knowledge of Medical Terminology, HCPCS, ICD-9 and CPT codes
Minimum of 3 years in a leadership roll
Required Certified Patient Accounts Technician (CPAT) certification or ability to successfully pass withing one year of hire

Grievance & Appeals Coordinator Resume Examples & Samples

Bachelors preferred in health service administration
A minimum of two (2) years work experience in a Managed Care environment and knowledge of the basic health care industry, managed care principles and medical terminology preferred
Intermediate level of proficiency and knowledge of Windows and Microsoft Office applications, including Excel, Access, PowerPoint and Outlook
Experience in grievance/appeals environment preferred

Appeals Coordinator Resume Examples & Samples

Minimum two years of experience processing Appeals, Reimbursements and Collections
Must have experience with Aging and AR reports
The ability to follow up, and meet deadlines a must
Knowledge of hospital billing and reimbursement a must
Experience with Managed Care, Government, and RAC Appeal's preferred
Excellent Written and Verbal Communications Skills a Must
Must be a team player

Senior Appeals Coordinator Resume Examples & Samples

Reviews clinical and medical records for completeness and determines administrative or clinical appeal. Assigns reviews to physician advisors and medical directors for those requiring medical necessity reviews
Enters all data related to appeals and case reviews into a database
Prepares and presents information on appeals to panels second-level multi-disciplinary committee
Participates in data gathering and analysis of reports regarding appeal activity as well as preparing for appeals audits, provides new employee training, monitors QI (Quality Improvement) activities of appeals department, and assists in the development of depart flows and implementations
Organizes volume of work and work-flow so that performance standards and proper procedures for appeals resolution according to client requirements and state and federal regulations are addressed

Grievances / Appeals Coordinator Resume Examples & Samples

Receipt and processing of all incoming mail for Appeals Department
Managing inventory of medical records through excel log and central archiving log
Scanning and coordination of all retrospective reviews and standard clinical reviews
Serve as backup to appeals and clinical administrative tasks

Temporary Grievances / Appeals Coordinator Resume Examples & Samples

This is a temporary role*
Maintains systems and processes for the timely and accurate resolution of all medical necessity and administrative denials, including the tracking of information via the Denial Log, sending adverse determination letters to providers and members (medical necessity only) within established time frames, and setting up and maintaining Denial Files
Maintains systems and processes for the timely and accurate resolution of all medically necessary and administrative appeals (as delegated); and ensuring compliance with all relevant regulations, accrediting standards, policies and procedures
When medical necessity appeals are delegated to Beacon, the Appeals Coordinator is responsible for logging the appeal in the Appeal Log, setting up an Appeal File, coordinating a conversation with the Beacon physician advisor and attending physician for expedited appeals and requesting the medical record, and once received, assigning to a physician advisor to review. S/he keeps the physician advisors informed of the required time frames to ensure that decisions are made in compliance with state, federal, NCQA and URAC standards and regulations. Once the appeal decision is made, the appeals coordinator composes a decision letter under the direction of the Director of Utilization Management and Clinical Operations sends to the member and provider, if indicated
Provides written and verbal education and training to staff, providers, and members
Generates all reports related to the appeals process
Assists in other quality management projects as required, including corporate audits, accreditation, quality improvement activities, and performance standard teams

Grievances / Appeals Coordinator Resume Examples & Samples

The Appeals Coordinator is responsible for the processing of all administrative appeals and presenting to the Administrative Appeal Committee for resolution
When medical necessity appeals are not delegated to Beacon, the Appeals Coordinator sends to the health plan, by secure fax, all information from the FlexCare system, and, if a second level appeal, all information from the first level of appeal decision. S/he enters the appeal into the Appeal Log and when the health plan notifies the Appeals Coordinator of the decision, s/he notifies the UR clinician and enters the decision into the Appeal Log
Maintains up to date Appeal Logs and Appeal Files that are in compliance with all state, federal, NCQA, URAC and other regulatory agency standards / regulations

Utilization Appeals Coordinator Resume Examples & Samples

Education: Bachelors, Associate Degree or diploma in Nursing
Experience: 3 years clinical experience. Experience in Case Management, Quality Management and/or Appeals Management preferred
Licensure: Current RN license, State of Michigan
Skills & Abilities: Keen analytical, critical thinking and problem-solving skills. Excellent written and verbal communication skills. Ability to meet deadlines and work under pressure. Word processing skills: Word, Excel, Access and OHS systems. Strong organizational skills

Medicare Advantage Grievance & Appeals Coordinator Resume Examples & Samples

Reviews grievances, appeals and disputes from Medicare members and providers applying regulatory, policy and procedure requirements to facilitate resolution
Utilization of data, medical records, coding, and claims information to research administrative or non-clinical aspects of appeals
Resolves grievances, appeals and disputes involving expressions of dissatisfaction, reimbursement, eligibility, coverage, utilization management, fees, payments and various other topics
Ensures compliance with organizational and regulatory requirements and timelines
Prepares customized correspondence to communicate final determinations with supporting statements
Documents issues, findings and final disposition of disputes
Adheres to required timelines for resolving and communicating final determinations
Facilitates escalated calls involving members and providers regarding, grievances, appeals, disputes and determinations
Collaboration with both internal and external stakeholders, such as vendors, provider network, claims, etc. to foster a clear consistent and comprehensive resolution
Florida Blue Medicare Advantage product knowledge
CMS Chapter 13 Knowledge
JIVA (ZeOmega) Experience