Job description
Position Purpose
The Appeals Coordinator will be responsible for the assisting in the appeals process from receipt to resolution for both provider appeals and member appeals, grievances, and complaints. This position will help investigate and resolve complex issues related to claims and enrollment, provider payment disputes, reversals, member authorization denials, and service quality complaints. The Appeals Coordinator will schedule member Grievance and Appeal Committee meetings for members to appeal authorization denials and/or complaints. Finally, this position is responsible for tracking and reporting on data related to these processes.
Essential Position Functions
The Appeals Coordinator will be responsible for the assisting in the appeals process from receipt to resolution for both provider appeals and member appeals, grievances, and complaints. This position will help investigate and resolve complex issues related to claims and enrollment, provider payment disputes, reversals, member authorization denials, and service quality complaints. The Appeals Coordinator will schedule member Grievance and Appeal Committee meetings for members to appeal authorization denials and/or complaints. Finally, this position is responsible for tracking and reporting on data related to these processes.
Essential Position Functions
- Coordinate the formal provider appeals process both internally for first level and externally for second level appeals. This includes: preparing files and sending them to the appropriate team members for review prior to appeal meetings.
- Coordinate the member grievance and appeal process. This includes member contact and scheduling, drafting and sending correspondence, meeting with various departments to investigate member concerns, tracking and preparing data for internal and external reporting.
- Research and resolve complex claims that pertain to membership or billing issues; send claim and payment reversals to appropriate staff if necessary.
Minimum Requirements of the Position
- Associate degree in relevant focus or equivalent experience required.
- One to two years of customer service experience focusing on customer complaint resolution is preferred;
- Knowledge of the health insurance industry preferred;
- Wisconsin Medicaid knowledge preferred;
- Organized and attentive to detail;
- Proficiency with Microsoft Word, Excel is required. Proficiency in PowerPoint preferred;
- Excellent verbal and written communication skills;
- Ability to work well with many different personality types;
- Excellent work ethic with the ability to work in a team environment as well as independently.
- Strong analytical and problem solving skills.
This full time position offers an outstanding benefit package, including three weeks of vacation the first year, a generous retirement plan, health and dental insurance, a wellness program, and much more! If you are interested in working for an organization focused on a team atmosphere and is dedicated to providing exceptional service submit your resume today! Send resume to: resumes@group-health.com. Group Health Cooperative of Eau Claire is an affirmative action and equal opportunity employer.
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