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Responsibilities
- Partner with the Manager to ensure the Appeals Department and Fund goals are implemented, accurately communicated, and achieved.
- Serve as a resource and provide guidance on 1st- and 2nd-level appeals to Appeals staff in the resolution of complex situations.
- Evaluate and monitor daily/weekly/monthly production, aging, and escalated reports, ensuring timely and appropriate action.
- Provide quantitative and qualitative analytical reports to identify trends and assess performance strengths or gaps.
- Resolve escalated calls and act as a liaison between Appeals staff and Appeals Management.
- Troubleshoot, resolve, and follow up on urgent matters.
- Conduct daily monitoring of calls using call management systems.
- Generate and review reports for trending system issues and repeat calls to improve member experience.
- Report findings to Manager and partner to conduct Listening Sessions and coaching for phone staff.
- Make recommendations for improvement on policies and procedures for Manager’s approval.
- Partner with Manager to train and develop new or modified policies, procedures, and workflows to ensure compliance with laws and regulations.
- Partner with other Appeal Coordinator(s) to conduct quality reviews of Appeals/Inquiries and correspondence.
- Ensure operational procedures and audit guidelines are followed, identify knowledge gaps, and provide re-training if needed.
- Ensure accuracy of data and Department of Labor (DOL) compliance.
- Communicate, orally and in writing, with members, providers, vendors, attorneys, and other professionals regarding appeals process, benefits, policies, and procedures.
- Perform additional duties and projects as assigned by management.
Requirements
- Bachelor’s degree in health care or related field, or equivalent years of work experience required.
- Minimum of four (4) years’ experience in claims adjudication, health care claims auditing, or benefit administration required.
- Minimum of two (2) years of experience in a Healthcare Appeals/Grievances environment preferred.
- Advanced knowledge of QNXT navigation, including all pertinent modules (Member, Claims, Provider, Medical Codes, etc.).
- Extensive knowledge of health claims policies and procedures; eligibility rules, Coordination of Benefits (COB), and 1199SEIU Family of Funds benefits required.
- Intermediate skills in Microsoft Word and Excel required.
- Strong knowledge of Medical Claims Processing Systems (QNXT), medical terminology, ICD 9/10, and CPT codes.
- Strong critical thinking and analytical skills.
- Effective troubleshooting and problem-solving abilities.
- Effective verbal and written communication skills.
- Effective time and project management skills.
- Ability to prioritize, be detail-oriented, multitask, and thrive in a fast-paced environment.
- Demonstrated quality control experience with an understanding of auditing procedures preferred.
Skills
- QNXT navigation
- Microsoft Word
- Microsoft Excel
- Medical Claims Processing Systems (QNXT)
- Medical terminology
- ICD 9/10
- CPT codes
- Critical thinking
- Analytical skills
- Troubleshooting
- Problem-solving
- Verbal communication
- Written communication
- Time management
- Project management
- Quality control
- Auditing procedures
Experience Level
- Minimum of four (4) years’ experience in claims adjudication, health care claims auditing, or benefit administration
- Minimum of two (2) years of experience in a Healthcare Appeals/Grievances environment
Education Level
- Bachelor’s degree in health care or related field
- Equivalent years of work experience