Appeals Coordinator

We are currently seeking a " Appeals Coordinator" for a Contract role with one of our clients in Phoenix, AZ. Please apply if you are interested and available for it.

• Receive, sort, classify, prioritize, manage, and distribute inbound G&A mail, fax, inter-office, and other correspondence according to policies and procedures, the CMS Managed Care and Prescription Drug Benefit Manuals, and other regulatory and procedural rules, guidelines, and timeframes.
• Prepare and assign individual case files to the appropriate G&A staff, continuously update tracking logs, databases, and reports, monitor and manage case status, timelines, statistics, regulatory compliance, and performance as required.
• Prepare and mail, fax, inter-office, and other outbound correspondence.
• Coordinate with enrolled members and providers submitting grievances and appeals to obtain additional information or clarification as required.
• Coordinate case files with G&A Staff (administrative evaluation of timely filing, claim payments, insufficient information, etc.), Quality Management staff (quality of care issues) Medical Directors (clinical evaluation of covered services, appropriate level of care, medical necessity, quality of care, etc.) and/or the Chief Medical Officer (clinical evaluation of covered services, appropriate level of care, medical necessity, quality of care, etc.) as required.
• Assist in the preparation and submission of cases to the Independent Review Entity (IRE), as required.
• Receive and coordinate Administrative Law Judge (ALJ), Medicare Appeals Council (MAC), and Federal District Court cases with the G&A staff, Medical Director, Legal, and other departments as required.
• Provide information regarding rights and responsibilities to enrolled members, providers, and other QHP departments as outlined in the Medicare Managed Care Manual.

• Math, communications, and business skills are normally demonstrated by a high school degree or equivalent.
• Intermediate PC user, including Client Word, Excel, Outlook, Power Point, and Adobe Acrobat Pro.
• Intermediate skill using office equipment, including copiers, fax machines, scanners, and telephones.