Appeals Coordinator

ESSENTIAL DUTIES AND RESPONSIBILITIES :

• Create patient specific appeal letters by incorporating the reason of medical necessity for why the denial should be overturned.
• Coordinate prescriber review and signature of completed letters.
• Prepare and submit appeal documentation to insurance companies.
• Communicate with patients, healthcare providers, and insurance companies to gather necessary information.
• Work closely with provider office point of contact(s) to obtain updated information in order to create appeals, draft letters, as well as follow pharmacy workflow steps to provide a streamlined appeal process for offices and payers.
• Maintain accurate and up-to-date records of all appeals processed
• Process fax queues, emails, answer incoming calls and adhere to all thresholds for authorization management.
• Monitor appeal deadlines and ensure timely submission of all required documents.
• Input accurate and clear data entry of call logs, important case notes and authorization details into CRM system.
• Collaborate with internal departments to ensure comprehensive appeal support.
• Research and stay current with changes in healthcare policies and regulations.
• Provide status updates and resolution outcomes to involved parties.
• Develop and implement strategies to improve the appeals process.
• Assist in training new staff members on the appeals process.
• Verify the accuracy and quality of data entry within authorizations prior to submission.
• To safeguard, protect, and always demonstrate proper handling of protected health information in accordance with all HIPAA laws and company policies/procedures.
• Assess, prioritize and resolve client issues using good listening and comprehension skills.
• Works cooperatively and provides coverage for responsibilities of co-workers when assigned or as the need arises.
• Demonstrate working knowledge of all facets of the role, relevant regulations & organizational and departmental policies & procedures.
• Escalate issues to management as appropriate.
• Perform other duties as assigned to support the business.

QUALIFICATIONS AND REQUIREMENTS :

• Strong understanding of medical terminology, insurance plans and authorization processes.
• Bilingual English/Spanish is a plus.
• Bachelor’s degree in healthcare administration, business or related field or minimum 3 year working in a healthcare setting managing or interpreting patient clinical notes or EMR files.
• Excellent written and verbal communication skills.
• Strong analytical and problem-solving skills.
• Previous experience in healthcare appeals or related field preferred.
• Working in a fast-paced environment for 2+ years is required.
• High level attention to detail and accuracy, with excellent investigative and research abilities.
• Strong customer service orientation.
• Ability to manage cases from multiple clientele programs and follow program business rules.
• Proficiency with data entry functions and Microsoft applications required.
• Ability to work independently and on a team
• Excellent communication, problem solving and customer service skills.
• Strong organizational /interpersonal skills; attention to detail and the ability to multitask proficiently.
• Ability to use multiple PC monitors and navigate through several.

PHYSICAL DEMANDS:
Requires sitting, standing, and occasional light lifting.

ProMod Rx will never ask for a financial commitment from an applicant, as part of our recruitment process. All interviews are conducted in-person OR through video conference invitations from official company emails. For inquiries, please contact our official recruitment team at View email address on click.appcast.io.

ProMod Rx is an Equal Opportunity Employer.

Equal Opportunity Employer


This employer is required to notify all applicants of their rights pursuant to federal employment laws.
For further information, please review the Know Your Rights notice from the Department of Labor.