Appeals & Grievances Coordinator II in Woburn, MA at Beacon Health Options

Date Posted: 7/28/2018

Job Snapshot

Job Description

About the Position:

We are currently seeking a dynamic Appeals & Grievances Coordinator II to join our office in Woburn, MA! The Appeals & Grievances Coordinator II is responsible for the processing, tracking and follow up of all medical necessity and administrative denials and appeals. This individual is required to have excellent communication and organizational skills, the ability to work cooperatively with health plan Appeal Divisions, the ability to provide excellent customer service to providers and members, and the ability to perform in potentially stressful situations, such as state, federal, NCQA, URAC or other regulatory/accrediting agency audits.

Position Responsibilities:

  • 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.
  • 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
  • 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.
  • Other duties as assigned. 

Position Requirements:

  • Education: High School diploma or GED equivalent required, Bachelor’s Degree in healthcare or human services preferred
  • Relevant Work Experience: 1 – 2 years experience in resolution of complex claims issues is preferred
  • Knowledge, skills, & Abilities:
    • Excellent analytical, problem solving, mathematical, and decision making skill
    • Excellent time management and organizational skill
    • Excellent written, verbal, interpersonal/negotiating skills
    • Knowledge of resources available within the organization to resolve internal/external problems and concerns is preferred
    • Work experience in health care/health insurance, conflict resolution or another related field is preferred

To Apply:

Click below on “Apply for this Position” to create a profile and apply for the position

Beacon Health Options is proud to be an Equal Opportunity and Affirmative Action Employer as well as a Drug Free and Tobacco Free Work Environment.  EOE/AA/M/F/Veterans/Disabled

#CB

#GD

PM16