Appeals Coordinator Job Description

Appeals Coordinator Job Description

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Appeals coordinator provides support to Sales & Marketing, including but not limited to preparing and maintaining Word and Excel documents.

Appeals Coordinator Duties & Responsibilities

To write an effective appeals coordinator job description, begin by listing detailed duties, responsibilities and expectations. We have included appeals coordinator job description templates that you can modify and use.

Sample responsibilities for this position include:

Overseeing the RAC and other governmental audits
Conducting audits to assure activities conform with regulatory and documentation requirements
Supporting policy development, implementation and staff education
Working with the multidisciplinary team to evaluate and improve the denial management, documentation and appeal process
Upload appeals documents into Medicaid's Electronic Case Record and upload the documents to the Division of Administrative Law/DHH SharePoint site
Monitor the reviewed cases for corrective actions taken by field staff
Responsible for logging, tracking and responding to all member and/or provider appeals of adverse determinations related to medical necessity administrative determinations
Render a written "informal resolution"' determination or case summary based on the information provided by all participants and make recommendation to SME if the case requires additional client review
Incumbents work independently to specific situations or in team to resolve problems and deviations according to current established practices
Ensures second level reviews have been performed and documented and may confer with medical directors, UM manager(s), inpatient care coordinators, SNF Care coordinators and facility personnel in determining denial information is processed timely and appropriately

Appeals Coordinator Qualifications

Qualifications for a job description may include education, certification, and experience.

Licensing or Certifications for Appeals Coordinator

List any licenses or certifications required by the position: CHDA, CDI, CHPS, RHIT, RHIA, TCM

Education for Appeals Coordinator

Typically a job would require a certain level of education.

Employers hiring for the appeals coordinator job most commonly would prefer for their future employee to have a relevant degree such as Associate and High School Degree in Education, Healthcare, Health, Therapy, Social Work, Nursing, Associates, Human Services, Psychology, Sociology

Skills for Appeals Coordinator

Desired skills for appeals coordinator include:

Sidewinder
Industry terminology
EMMA
NCQA
Word
Excel
Word and Excel
Best practices
CMS
Continuity of benefits and medical necessity guidelines

Desired experience for appeals coordinator includes:

Maintains UM/CM tool
Coordinate/prints/mails/faxes denial letters, NOMNC, DENC when indicated
Acts as a point person for QIO appeals
Serves as a liaison for requests for information from QIO or health plan staff
Current Licensure as a Physical Therapist (PT), Registered Nurse (RN), Licensed Practical Nurse (LPN) or Licensed Vocational Nurse (LVN)
At least three years experience in an acute care, managed care or social services environment

Appeals Coordinator Examples

1

Appeals Coordinator Job Description

Job Description Example
Our innovative and growing company is looking to fill the role of appeals coordinator. Please review the list of responsibilities and qualifications. While this is our ideal list, we will consider candidates that do not necessarily have all of the qualifications, but have sufficient experience and talent.
Responsibilities for appeals coordinator
  • Generally works on issues that are of a complex nature
  • Serves as an internal resource for lower level behavioral health appeal coordinators and staff
  • Documents and logs information on tracking systems and mainframe systems
  • Generates appropriate written correspondence to providers, members, and regulatory entities
  • Participates in projects impacting development, interpretation, and implementation of medical policy or other managed care initiatives
  • May confer with medical directors, Centralized Clinical Team Manager(s), pre-service coordinators, inpatient care coordinators, and SNF Care coordinators in determining denial information is processed timely and appropriately
  • Maintains a daily activity tracker to monitor workload and submits weekly to Denial Team Lead and/or Denial Team Manager
  • Coordinate /mails/faxes denial letters when indicated
  • Participates in projects impacting development, interpretation, and implementation of medical policy or other managed care initiative
  • If you are 50 miles to this office, will be required to work on-site
Qualifications for appeals coordinator
  • Requires an MS in social work, RN or degree in a related behavioral health field
  • Four years of experience in a managed care/healthcare setting
  • Current active unrestricted license in CA such as a Licensed Clinical Social Worker, Marriage and Family Therapist, Clinical Psychologist, Licensed Professional Counselor or RN
  • Self-starter with the ability to prioritize daily work load
  • 1+ years practical work experience in a claims, customer service, or data entry position
  • Enters denials and requests for appeal into information system and prepares documentation for further review
2

Appeals Coordinator Job Description

Job Description Example
Our company is hiring for an appeals coordinator. Thank you in advance for taking a look at the list of responsibilities and qualifications. We look forward to reviewing your resume.
Responsibilities for appeals coordinator
  • Processes technical appeals by writing letter of appeal with supporting documentation
  • Reviews processes and recommends changes to incorporate state-of-the-art technology as appropriate
  • Acts as liaison to IT to ensure technology systems are properly installed and maintained
  • Manages design and production of large direct mail and email campaigns
  • Lead provider education based upon periodic reviews of clinical and/or surgical charges and findings of documentation reviews via account sampling or meeting findings (i.e., Timely Filing)
  • Recommend or educate others on policies regarding the proper use of CPT Codes, modifiers and diagnosis codes in order to comply with regulations set forth by Medicare, Medicaid, Managed Care, PPO Contracts, Indemnity Insurers, and all other healthcare payers
  • Communicates directly with members of patient care team
  • Educates patient care team members about payor specific requirements
  • Assists Revenue Cycle with the collection of clinical/medical necessity documentation
  • Serves as a resource for the authorization/referral process, as appropriate
Qualifications for appeals coordinator
  • Ability to interact effectively and professionally with all levels of management internal and external customers
  • Independent Medical Review process knowledge preferred
  • Researches issues utilizing systems and other available resources
  • Requests and obtains medical records, notes, and/or detailed bills as appropriate to assist with research
  • Determines appropriate language for letters and prepare responses to provider grievances / appeals
  • Write annotated notes as appropriate
3

Appeals Coordinator Job Description

Job Description Example
Our innovative and growing company is looking to fill the role of appeals coordinator. Thank you in advance for taking a look at the list of responsibilities and qualifications. We look forward to reviewing your resume.
Responsibilities for appeals coordinator
  • Functions as a Subject Matter Expert in process areas
  • Analyzes data submitted for Independent Medical Review
  • Carries out fact finding and analyses on those cases deemed complex in nature or requiring adjudication
  • Tracks and meets required deadlines for complex cases or other assigned tasks
  • Assists leadership through research of data and/or authoring reports
  • Analyzes data using all applicable state law, state regulations, process documents, and other sources as defined by the client contract
  • Works independently on specific situations or on a team to resolve problems and deviations according to current established practices
  • Answers and responds to phone calls/emails from participants in the Independent Medical Review process
  • Reviews patient medical records and utilizes clinical and regulatory knowledge & skills knowledge of payer requirements to determine why cases are denied and whether an appeal is required
  • Collaboratively utilizes pre-existing criteria and other resources and clinical evidence to develop sound and well-supported appeal arguments, where an appeal is warranted
Qualifications for appeals coordinator
  • Minimum of 3 to 5 years of experience in Care Management or Utilization Management
  • College or professional certification/credential in the area of leave, insurance or disability administration desired (CDMS, CRC, CCM)
  • Elevates appropriate appeals to the Appeals Specialist
  • Generates and mails denial letters
  • Receive and resolve provider inquiries related to claims
  • Act as a liaison between the providers and health plan as appropriate
4

Appeals Coordinator Job Description

Job Description Example
Our growing company is looking for an appeals coordinator. We appreciate you taking the time to review the list of qualifications and to apply for the position. If you don’t fill all of the qualifications, you may still be considered depending on your level of experience.
Responsibilities for appeals coordinator
  • Conducts research for supporting clinical evidence to support appeal arguments when existing resources are unavailable
  • Proactively prepares and provides feedback to various departments, physicians/service, and clients and participates in client meetings
  • Actively manages, maintains, and communicates to appropriate stakeholders and physician advisor denial and appeal activities, trends, outcomes, and recommends corrective action plans
  • Responsible for discussing documentation-related and level of care decisions with clients
  • Reviews abstract information from various documented patient medical records
  • Conducts comprehensive analytic review of systems and clinical documentation to determine denials trends
  • Continuously manages administrative functions to ensure quality and timeliness, manages accurate and timely activity and performance reports (DNFB, Denials pre and post claims)
  • Analyzes/Synthesizes complex or diverse information
  • Gather documentation for the IRE (independent review) process
  • Combine strong organizational skills and effective relationship building to analyze, monitor and track all incoming clinical and financial documentation for submission and processing by the Authorization and Appeals Management Nurse
Qualifications for appeals coordinator
  • Support external Provider Services Representatives with claim inquiries or other questions
  • Assist with interdepartmental issues to help coordinate problem solving in an efficient and timely manner
  • Creates and/or maintains statistics and reporting
  • Work with Customer Service to resolve balance bill issues and other member complaints regarding providers
  • Researches and documents each Provider Dispute and/or Member Appeal in a thorough, professional and expedient manner
  • Coordinates workflow between departments and interface with internal and external resources
5

Appeals Coordinator Job Description

Job Description Example
Our company is searching for experienced candidates for the position of appeals coordinator. Thank you in advance for taking a look at the list of responsibilities and qualifications. We look forward to reviewing your resume.
Responsibilities for appeals coordinator
  • Serves as the liaison with Authorization and Appeals Nurse, marketing staff and the admissions associates for each market
  • Performs and provides additional administrative support services for the precertification and appeals nurse
  • 3 - 5 years on the job or equivalent training / experience in managed care procedures, or previous SharePoint experience
  • Experience in a healthcare management / office setting required
  • Review research performed by operational areas (Call Center, Claims, Medical Management, Provider Relations, ) to assure the appropriate resolution to the appeal has been achieved
  • Perform all other duties assigned by the manager and/or supervisor
  • Monitor weekly Medical Record Requests for Medicare accounts
  • Monitor key health plans Open/Unfulfilled Requests on health plans’ website
  • Utilize denial tracking software to regularly notate/respond to EHR tasks and requests
  • Process Outpatient Medical Necessity denial appeals
Qualifications for appeals coordinator
  • Formulates conclusions
  • Inputs all Provider Disputes and/or Member Appeals into the database, on a daily basis and track per Departmental policies
  • 5 years experience in claims review and Provider Dispute or Member Appeal resolution
  • Experience in reviewing all types of medical claims, HCFA 1500, Outpatient/Inpatient UB92, Universal Claims, Stop Loss, Surgery, and Anesthesia, high dollar complicated claims, COB and DRG/RCC pricing
  • MS in social work, RN or degree in a related behavioral health field
  • 4 years of behavioral health utilization management experience

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