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

Date Posted: 3/11/2019

Job Snapshot

Job Description

About the Position:

We are currently seeking a dynamic Appeals & Grievances Coordinator to join our team in Woburn, MA! The Appeals & Grievances Coordinator 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:

  • Receive and process all incoming mail for the Appeals Department
  • Maintain a current knowledge of plan products, policies and procedures with the ability to relate this information in a clear, concise and understandable manner to member, providers, and other customers, both internal and external
  • 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
  • Manage the receipt, investigation and resolution of standard complaint and appeal issues in a timely and highly effective manner
  • Interface with the appropriate Beacon management and staff at all levels to present and summarize Complaint and Appeal cases
  • Maintain confidentiality of all protected health information in accordance with state and federal guidelines and corporate policies and procedures
  • Maintain knowledge of all system, contractual, compliance standard changes and policy updates, and attend additional training sessions as necessary
  • Complete projects and other research tasks as assigned by area management
  • 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
  • Other duties as assigned

Position Requirements:

  • Education: High School diploma or GED equivalent is required, Associate or Bachelor’s degree in Human Services (Social Work, Psychology, and/or Sociology) is 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:

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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