Appeal Coordinator I, Govt Programs

Moda Health•Milwaukie, OR

3d•Remote

About The Position

Investigate and respond to medical, pharmacy and dental grievances, complaints, appeals, and inquiries for the organization. Respond to outside regulatory inquiries as needed. This position is in Government Programs. This is a FT WFH position.

Requirements

High School diploma or equivalent.
6 months to 2 years of experience of medical/dental claims processor or customer service preferred.
Demonstrated knowledge of CMS rules for Medicare and Medicaid grievance, complaint and appeal processes preferred.
Knowledge and understanding of complaint and appeal procedures preferred.
Ability to interpret benefit contracts and/or Moda Health administrative policies, products, and business lines.
Demonstrated strong reading, verbal, written and interpersonal communication skills.
Demonstrated initiative, analytical, problem solving, and organizational skills.
10 key proficiency of 105 kspm on a numeric keypad.
Type a minimum of 25 wpm accurately on a computer keyboard.
Demonstrated proficiency in computer applications such as Word, Excel, or other core operating systems.
Ability to work well under pressure and meet deadlines while completing a high volume of work.
Ability to maintain confidentiality and project a professional business image.
Ability to adhere to Moda Health attendance policies and work assigned schedule which may include some overtime and occasional weekend and Holiday coverage.
Ability to communicate positively, patiently, and courteously.

Responsibilities

Research all grievances, complaints, correspondence, and appeals.
Perform a complete review at each stage of the complaint/appeal process and ensure the appropriate documentation, including claim review to determine over/underpayment.
Respond in writing (or orally when appropriate) to requests, grievances, complaints, and appeals within the mandated timeframes.
Ability to maintain a full caseload.
Communicate effectively and appropriately with other departments to ensure complete and fair reviews of grievances, complaints, and appeals.
Communicate by letter and/or telephone with members, claimants, independent review entities, attorneys, and providers regarding claims/policies on Moda Health benefit plans.
Interpret contracts (evidence of coverage; handbooks) and determine actions required.
Respond to independent review entity requests for member case files within the stipulated timelines and ensure appropriate documentation required for reporting.
Staff may also be required to respond to DFR requests or attend Medicaid hearings as a representative of the company.
Work with appropriate departments to effectuate decisions.
Meets the departments established production and accuracy standards for case completion.
Accurately document in system the outcome of grievances, complaints, and appeals.
Other duties as assigned