Appeals Coordinator (Monday-Friday)

PacificSource Health Plans • Springfield, OR

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About The Position

Looking for a way to make an impact and help people? Join PacificSource and help our members access quality, affordable care! PacificSource is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to status as a protected veteran or a qualified individual with a disability, or other protected status, such as race, religion, color, sex, sexual orientation, gender identity, national origin, genetic information or age. PacificSource values the diversity of our community, including those we hire and serve. We are committed to creating and fostering a work environment in which individual differences and diversity are appreciated, respected and responded to in ways that fully develop and utilize each person’s talents and strengths. Coordinate the internal appeals and grievances process by supporting entry of requests in a meaningful and timely manner. Provide support as needed for the completion of appeals and grievances. Communicate information about appeals and grievances processes and outcomes to members and providers verbally and/or in writing. Support member and provider experience. Essential Responsibilities: Oversee and coordinate all Appeal activities ensuring response deadlines are met in accordance with applicable best practice, state and federal guidelines. Draft and provide acknowledgements by applicable method, to inquiries and appeals as required by regulations, PacificSource policy and department process standards. Ensure accurate and complete entry of case specific information into the Health Management Platform. Review original adverse benefit determination and provide information in the case to inform further process. Prepare and provide response and resolution by applicable method to inquiries and appeals as required by regulations, PacificSource policy and department process standards. Collaborate with team members to manage the timeliness of cases. Identify needs of the case spanning Commercial, Medicaid, and Medicare plans based on applicable state, federal, and NCQA guidelines. Supporting Responsibilities: Assist the Appeals and Grievances Support team in the entry of new appeals and grievances into the system. Meet department and company performance and attendance expectations. Follow the PacificSource privacy policy and HIPAA laws and regulations concerning confidentiality and security of protected health information. Perform other duties as assigned.

Requirements

• Minimum of two years customer service, claims processing or health insurance industry experience required.
• Requires strong research, analytical and data entry skills.
• Must have basic math skills, the ability to work under strict deadlines, and excellent organizational skills.
• High School Diploma required

Nice To Haves

• 1 year of technical writing and conflict resolution experience preferred.
• Bachelor’s degree or equivalent experience preferred.
• Experience using Facets, Onbase, and other software packages used by PacificSource is strongly preferred.

Responsibilities

• Oversee and coordinate all Appeal activities ensuring response deadlines are met in accordance with applicable best practice, state and federal guidelines.
• Draft and provide acknowledgements by applicable method, to inquiries and appeals as required by regulations, PacificSource policy and department process standards.
• Ensure accurate and complete entry of case specific information into the Health Management Platform.
• Review original adverse benefit determination and provide information in the case to inform further process.
• Prepare and provide response and resolution by applicable method to inquiries and appeals as required by regulations, PacificSource policy and department process standards.
• Collaborate with team members to manage the timeliness of cases.
• Identify needs of the case spanning Commercial, Medicaid, and Medicare plans based on applicable state, federal, and NCQA guidelines.
• Assist the Appeals and Grievances Support team in the entry of new appeals and grievances into the system.
• Meet department and company performance and attendance expectations.
• Follow the PacificSource privacy policy and HIPAA laws and regulations concerning confidentiality and security of protected health information.
• Perform other duties as assigned.

Benefits

• Flexible telecommute policy
• Medical, vision, and dental insurance
• Incentive program
• Paid time off and holidays
• 401(k) plan
• Volunteer opportunities
• Tuition reimbursement and training
• Life insurance
• Options such as a flexible spending account.

What This Job Offers

• Job Type: Full-time
• Career Level: Entry Level
• Education Level: High school or GED