Appeals & Grievances Coordinator in Newark, NJ at Beacon Health Options

Date Posted: 3/28/2018

Job Snapshot

Job Description

About the Position:

We are currently seeking a dynamic Grievance and Appeals Clinical Coordinator to join our team in Newark, NJ!  The Grievance and Appeals Clinical Coordinator will be responsible for ensuring that the Peer Advisor review and appeals process is efficiently administered according to regulatory, accreditation, and contractual requirements.

Position Responsibilities:

  • Maintains systems and processes for the timely and accurate resolution of all medical necessity denials, including the tracking of information, system documentation, sending adverse determination letters to providers and members within established client service level agreements, performance guarantees and regulatory requirements.
  • Review Peer Advisor and/or Clinician determinations to ensure that regulatory, accreditation, and client requirements are adhered.
  • Compose decision letter under the direction of utilization management, clinical operations, and issue final determination response to member and provider.
  • Responsible for verbal communications of denial and appeal outcomes to member and providers.
  • Manages case assignments including appeal review scheduling, point of contact for appeal requestor to respond to questions concerning the appeal process, quality assurance process for appeal resolution letter, and liaison for functional inter-departmental dependencies.
  • Responsible for processing fax and email receipts of appeal requests including building appeal cases, triage to clinical operations and/or National scheduling, and detail case documentation.
  • Assists in other quality management projects as required including client and corporate audits, accreditation, quality improvement initiatives, and performance standard teams.
  • Other duties as assigned.

Position Requirements:

  • Education: High School diploma or GED equivalent required, BS/BA degree in psychology, social work or other allied behavioral health discipline preferred
  • Relevant Work Experience: 1 year of experience working in a hospital, psychiatric facility, medical office or insurance environment is preferred
  • Knowledge, Skills & Abilities:
    • Previous experience handling appeals/complaint highly preferred
    • Must be well organized, have solid computer skill sets, and have the ability to function independently
    • Must demonstrate excellent verbal and written skills. Requires an understanding of medical terminology

To Apply:

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

Beacon Health Options company 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

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