Appeals Coordinator (Hybrid)

Responsibilities

• Partner with the Manager to ensure the Appeals Department and Fund goals are implemented, accurately communicated, and achieved. o Serve as a resource and provide guidance on 1st- and 2nd-level appeals to Appeals staff in the resolution of complex situations. o Evaluate and monitor daily/weekly/monthly production, aging, and escalated reports and ensure they are acted on timely and appropriately; provide quantitative and qualitative analytical reports to identify trends, objective assessments of strengths or gaps in performance to Manager. o Resolve escalated calls and act as liaison between Appeals staff and Appeals Management; troubleshoot, resolve, and follow up on urgent matters.
• Conduct daily monitoring of calls using call management systems; generate and review reports for trending system issues, and repeat calls for an improved member experience and report findings to Manager; partner with Manager to conduct Listening Sessions and coaching for phone staff.
• Make recommendations for improvement on policies and procedures for Manager’s approval and partner with Manager to train and develop new or modified policies, procedures, and workflows to ensure compliance with internal and external (Department of Labor (DOL), ERISA, etc.) laws and regulations while providing staff with a roadmap to day-to-day operations.
• Partner with other Appeal Coordinator(s) to conduct quality reviews of Appeals/Inquiries and correspondence to ensure operational procedures and audit guidelines are being followed, identify where there may be a lack of knowledge or re-training if needed (e.g., timely departmental follow-ups, accuracy of response/determination letters, etc.), and ensure accuracy of data and DOL compliance.
• Communicate, oral and written, with members, providers, vendors, attorneys, and other professionals via email, fax, and telephone regarding appeals process, benefits, policies and procedures including plan changes and updates.
• Perform additional duties and projects as assigned by management.

Qualifications

• Bachelor’s degree in health care or related field, or equivalent years of work experience required.
• Minimum of four (4) years’ experience in claims adjudication, health care claims auditing, or benefit administration required, and a minimum of two (2) years of experience in a Healthcare Appeals/Grievances environment preferred.
• Advanced knowledge of QNXT navigation, including all pertinent modules (Member, Claims, Provider, Medical Codes, etc.).
• Extensive knowledge of health claims policies and procedures; eligibility rules, Coordination of Benefits (COB), and 1199SEIU Family of Funds benefits required.
• Intermediate skills in Microsoft Word and Excel required; strong knowledge of Medical Claims Processing Systems (QNXT), medical terminology, ICD 9/10, and CPT codes.
• Strong critical thinking and analytical skills, with effective troubleshooting and problem-solving abilities.
• Effective verbal and written communication skills.
• Effective time and project management skills, with the ability to prioritize, be detail-oriented, multitask, and thrive in a fast-paced environment.
• Demonstrated quality control experience with an understanding of auditing procedures preferred.