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Coordinator Appeals

Amerihealth

This is a Full-time position in Palm Beach Gardens, FL posted April 23, 2021.

Your career starts now. We’re looking for the next generation of health care leaders.

At AmeriHealth Caritas, we’re passionate about helping people get care, stay well and build healthy communities. As one of the nation’s leaders in health care solutions, we offer our associates the opportunity to impact the lives of millions of people through our national footprint of products, services and award-winning programs. AmeriHealth Caritas is seeking talented, passionate individuals to join our team. Together we can build healthier communities. If you want to make a difference, we’d like to hear from you.

Headquartered in Philadelphia, AmeriHealth Caritas is a mission-driven organization with more than 30 years of experience. We deliver comprehensive, outcomes-driven care to those who need it most. We offer integrated managed care products, pharmaceutical benefit management and specialty pharmacy services, behavioral health services, and other administrative services. Discover more about us at www.amerihealthcaritas.com.

Responsibilities:

Reporting to the Director Operations, this position is responsible for the coordination of appeals submitted by providers, the analysis of claims and appeals and the review of medical management authorizations.

  • Manages and adjudicates member and provider disputes arising under the Grievance System including member grievances, appeals and requests for hearing and provider claim and disputes.
  • Investigates findings of encounter denials and explains to management underlying reasons for identified data quality issues.
  • Creates corrective action plan listing issues, responsible parties and projected resolution dates.
  • Incorporates corrective action steps into encounter quality improvement plan
  • Participates in quarterly meeting with governing body and reports comprehensive list of data quality issues present during for given period. 
  • Communicates with providers to resolve problems with appeal requests that are not submitted according to Plan’s policy.
  • Maintains an accurate, timely and complete record of appeals in authorization system.
  • Completes the appeals process within an established timeframe documented in current Plan’s policy.
  • Collects, analyzes and reviews historical authorization information to incorporate into departmental appeal documentation.
  • Accountable for compliance with record retention plan according to Plan’s policy.
  • Coordinates the presentation of appeals to the Appeals Committee and participates as a member.
  • Communicates decisions (in writing) made by the Appeals Committee to providers within Plan timeframe.
  • Maintains minutes of Appeals Committee meetings. 
  • Updates or creates authorizations for services that have been appealed and communicates this information to the Medical Claims department.
  • Identifies and reports on provider issues appropriate for use as educational opportunities to the Provider Services management staff.
  • Prepares written case summaries and forwards to the Medical Director for review taking appropriate action as indicated by Medical Director’s determination to ensure timely resolution.

Education/Experience:

  • High School Diploma or equivalency required.
  • College Degree or equivalent education and experience preferred  w/emphasis in health services administration or equivalent experience in medical office admin and/or claims admin, especially Medicaid billing.
  • 1-3 years medical office billing experience.
  • 3-5 years Microsoft Word, Excel and PowerPoint, and Access database experience.