Senior Appeals Coordinator

Highmark Health

5d • $20 - $30

About The Position

GENERAL OVERVIEW: Conducts review of claims on services questioned on appeal by the provider or facility of the service, beneficiary, government program or other interested parties. Renders an independent decision based on research, and initiates a response to the inquirer and appropriate parties to the appeal in the form of an adjustment to payment, refund request for overpayment, or written correspondence when upholding the processing of service.

Requirements

• Minimum High School diploma or GED required for all levels
• 5-10 years of related, progressive experience.
• Good verbal and written communication skills
• Solid customer service skills
• Ability to make independent decisions relating to claims processing accuracy
• Sound research and decision making to respond to inquiries
• Thorough knowledge of claims policies and benefits, processing instructions, as well as medical terminology
• Knowledge of processing systems

Nice To Haves

• None

Responsibilities

• Research and determine validity of inquiries identified as appeals received from members. Review additional documentation to determine if information needs to be forwarded to a clinician for additional consideration.
• Render an independent decision based on research of the initial claim processing activity, documented procedures and policies, and information supplied with the appeal request.
• Respond timely to inquiries that constitute an appeal or reopening of an initial claim determination, including generating written correspondence to the inquirer and other parties to the appeal.
• Ensure members’ appeal right are upheld and the corporate is in compliance with government guidelines.
• Identify errors made during claims processing and follow procedures to initiate referrals and forward requests to appropriate units as necessary. Resolve adjustment claims which suspended.
• Provide input to management regarding current inventory issues for inquiry analysis.
• Review and apply new and updated procedures and guidelines. Identify quality-related problems and recommend process improvements.
• Other duties as assigned or requested.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: High school or GED