Appeals Coordinator II

MedReview•New York, NY

3d•Remote

About The Position

Join a Leader in Healthcare Payment Integrity At MedReview, our mission is to bring accuracy, accountability, and clinical excellence to healthcare. As a recognized leader in payment integrity solutions, we specialize in DRG Validation, High-Cost Outlier Reviews, Readmission Reviews, and healthcare claims auditing that help ensure quality and financial accuracy across the healthcare system. We are seeking a detail-oriented and experienced Appeals Coordinator II to join our remote team. This role is ideal for a healthcare professional who thrives in a fast-paced environment, enjoys investigative work, and has a passion for resolving complex provider appeals and inquiries.

Requirements

Associate's Degree or equivalent combination of education and relevant experience.
Minimum of 3 years of experience in the healthcare industry.
Strong analytical, critical thinking, and problem-solving abilities.
Excellent organization, prioritization, and time management skills.
Outstanding written and verbal communication skills.
Ability to manage multiple priorities and meet strict deadlines.
Self-starter who takes initiative and works independently.
Ability to remain professional and composed in a deadline-driven environment.
High-speed internet connection (100 Mbps recommended).
Secure Wi-Fi connection.
Dedicated workspace with minimal interruptions to ensure HIPAA and PHI compliance.
Ability to sit and work on a computer for extended periods.

Nice To Haves

Experience with inpatient claims review.
Knowledge of DRG and High-Cost Outlier claims.
Experience using WebStrat for DRG pricing.
Understanding of healthcare claim payment methodologies.
Advanced proficiency with Microsoft Office, particularly Excel.
Previous experience handling healthcare appeals, grievances, or provider relations.

Responsibilities

Prepare and distribute case files for External Reviews and State Fair Hearings.
Manage and monitor appeals from non-participating providers.
Research, investigate, and resolve provider appeals, grievances, and complaints.
Draft professional, customized written responses to provider inquiries and complaints.
Ensure all appeals and grievances are processed accurately and within required timelines.
Collaborate with leadership, clinical staff, account managers, and other internal stakeholders to resolve complex cases.
Track and maintain appeal and grievance records through completion.
Review appeal cases and determine outcomes independently or alongside clinical review staff.
Utilize subject matter experts and organizational resources to support effective resolutions.
Make sound decisions regarding research, investigation, and case outcomes.
Provide guidance and support to Appeals Coordinators as needed.
Perform other duties as assigned.