Appeals Coordinator Level Ii

At MedReview, our mission is to bring accuracy, accountability, and clinical excellence to healthcare. As such, we are a leading authority in payment integrity solutions including DRG Validation, Cost Outlier and Readmission reviews.

Under the direction of the Appeals Department leaders, the Appeals Coordinator level II team member will assist Appeals leadership with daily administrative work within the department.

The Appeals Coordinator level II performs research, investigation, and analysis of appeals, grievances, and other types of complaints filed by providers and clients to administer timely resolution. Responsible for all aspects of nonclinical appeals and inquiries

Responsibilities

This list does not represent all responsibilities for this position. Candidate must understand and be willing and able to assume roles and responsibilities other than these to meet the needs of the department and NYCHSRO/MedReview in general.

• Consults with managers on problem cases and interfaces with clinical supervisors, account managers, and other personnel in resolving health plan requests or provider inquiries
• Independently prepare well written, customized responses to all provider inquiries/complaints that appropriately and completely address the complainant’s issues and are structurally accurate.
• Ensure timely review, research, and resolution of appeals, grievances, and complaints within guidelines. Ensures that all complaints are handled and resolved in compliance with timeliness requirements, and at the highest standards for accuracy
• Consults with subject matter experts and resources available within organization to assist in appeal and complaint resolution.
• Make critical decisions regarding research and investigation to appropriately resolve all inquiries
• Review and determine outcome of appeal/grievance, either independently or in conjunction with clinical appeal staff.
• Serve as a liaison to Appeal Coordinator providing guidance and expertise to ensure timely resolution of cases
• Log and track grievances, appeals, and other types of complaints as needed.
• Manage and monitor all appeals from Non-Participating providers
• Prepare and disseminate case file for External Reviews and/or State Fair Hearing
• Other duties and responsibilities as assigned

Requirements

• Experience in inpatient claims, DRG and High-Cost Outlier claims preferred
• 3+ years’ experience working in the health care industry
• Ability to manage priorities in a complex environment.
• Excellent written and verbal communication skills
• Ability to cope well with ambiguity and stressful situations
• Excellent problem solving and analytical skills required
• Excellent organization and time management skills required
• Ability to meet strict, time sensitive deadlines
• Knowledge in claim payment methodology
• Must show patience and the ability to remain calm under pressure in an atmosphere of frequent interruptions
• Takes initiative to proactively identify and solve problems
• Good MS Office skills. Particularly Excel
• Associates Degree. Additional years of related experience may be used in place of education requirements
• Experience in DRG Pricing using WebStrat

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