Member Appeals Coordinator
AllWays Health Partners

Job Info

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For over 30 years, AllWays Health Partners has delivered value to our members and worked to improve access to care and coverage. As a member of Mass General Brigham, AllWays is a health plan at the forefront of innovation, advancing a highly integrated model of value-based care with one of the world's leading health care systems. Together, we are transforming the customer experience, keeping our members and patients at the center of everything we do. Bring your unique talents and join us as we strive to create a world where all people live healthier lives.

The Member Appeals Coordinator will coordinate, process, and document all aspects of Member appeals. This role will be responsible for maintaining Appeals tracking information, working closely with internal AllWays Health Partners departments to quickly resolve appeals, communicating orally and in writing to all involved parties during the appeal process, and compiling reports for analysis purposes. The Appeals Coordinator will also present appeal cases to the Appeals Committee. Thorough knowledge of all applicable AllWays Health Partners' appeal policies and procedures, MassHealth, the Health Connector, and DOI regulations, and Commercial product contractual obligations is a key element of this role. Strong customer service and communication skills during regular interactions with customers, providers and external agencies.

ESSENTIAL FUNCTIONS
• Handle a large volume of incoming appeals from receipt through resolution, ensuring that all appeals are resolved within contractual timeframes.
• Maintain a centralized tracking system to support reporting and analysis of member appeals.
• Compile appeal files containing all documentation, research, acknowledgment and resolution letters and any other pertinent information related to the member appeal.
• Thoroughly research all administrative appeals, gather any missing or required information, and prepare appeal cases for presentation to the Appeals Committee.
• Triage all clinical and pharmacy appeals to the clinical department for review; track resolution timeframes and ensure all appeal documentation is returned for appeal file.
• Process member appeals while adhering to specifically defined appeals policies for MassHealth and Commercial members.
• Assist in the notification to external agencies of appeal outcomes per MassHealth Board of Hearing and the Division of Insurance's Office of Patient Protection requirements.
• Prepare files for external review when informed of an external hearing.
• Participate in BOH hearings, as assigned.
• Responsible for timely written notification to members on the acknowledgement and resolution of an appeal.
• Facilitate the reversal of claims payment or authorization entry if denial is overturned.
• Stay informed of changes related to AllWays Health Partners authorization and claims payment rules, benefit plans, and new products.
• Identify internal systematic or procedural issues to the Manager of Appeals and Grievances for process improvement.
• Sensitivity to confidential materials in all cases is expected and required.
• Knowledge of eligibility and claims processes required.
• Anticipates and meets, or exceeds, internal and/or external customer expectations and requirements; establishes and maintains effective relationships with customers and gains their trust and respect.
• Other duties as assigned with or without accommodation.

WORKING CONDITIONS AND PHYSICAL EFFORT
• Work is normally performed in a typical office work environment.

Qualifications
KNOWLEDGE AND EDUCATION

Required:
• Bachelor Degree
• Superior verbal and written communication skills
• MassHealth and Commercial insurance knowledge essential
• Excel and Word proficiency
Preferred/Desired:
• Bi-lingual a plus

EXPERIENCE

Required:
• 3-5 years in a customer service environment, preferably in a health care administration or insurance setting.
• A complete understanding of claim forms, ICD-9, CPT-4, HCPCS and Revenue Codes Required.
• Sensitivity to confidential materials and the ability to maintain a professional demeanor in potentially difficult situations involving providers, members and internal customers.
• Able to understand and adhere to complex regulations.
Preferred/Desired:
• Appeals experience preferred.

SKILLS/COMPETENCIES

• Ability to build customer confidence, demonstrates commitment to customer satisfaction, set achievable customer expectations, ensure commitments to customers are met.
• Approachable, good listening skills.
• Able to understand the expectations of Members and Providers as well as internal customers.
• Must be self-motivated, detail oriented, and able to work independently in a dynamic environment.
• Demonstrate commitment to increasing customer satisfaction.
• Assume responsibility for solving customer problems.
• Ability to meet required timelines, and maintain professional demeanor.
• Good organization skills.
• Ability to multi-task.
• Demonstrates AllWays Health Partners' Core Values of Service Excellence, Quality Care, Diversity, Responsibility and Relationships.
• Respects the talent and unique contribution of every individual, culture and ethnic group and treats all people in a fair and equitable manner.
• Exercises self-awareness; monitors impact on others; is receptive to and seeks out feedback; uses self-discipline to adjust to feedback.
• Accountable for delivering high quality work.

INDEPENDENT ACTION
• Under direct supervision of the Manager of Appeals & Grievances this individual should be self-motivated and assume responsibility and ownership of responsibilities

ORGANIZATIONAL RELATIONSHIPS/SCOPE
• This position reports to Manager of Appeals and Grievances, and interacts with internal and external stake holderks.

EEO Statement
AllWays Health Partners' mission targets a diverse population and our employees are just as diverse. As an equal opportunity employer, AllWays Health Partners recognizes the power of a diverse community and encourages applications from individuals with varied experiences, perspectives, and backgrounds.

DISCLAIMER
The above statements are intended to describe the general nature and complexity of the work being performed by personnel assigned to this classification, and do not represent an exhaustive list of all tasks, duties, and responsibilities required of personnel assigned to this position.

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