Appeals Coordinator - Jefferson Health Plan

Job Details Works under the general supervision of the Provider Appeals Team Lead and Provider Appeals Manager to prepare and manage the Inpatient Services appeals throughout the Appeals Process. The position is responsible for receiving, processing, routing, and monitoring provider inpatient appeals at each step of the appeals process and assuring timely resolution of those appeals. Position exercises attention to detail, ability to manage multiple tasks, documentation of work, and accountability for activities regarding provider inpatient appeals processing and outcomes. Job Description Coordinate and review Inpatient Facility appeal request date of receipt, timeliness of submission, and dates of service of all documentation submitted for appeal. Request additional information when required to prepare an appeal for external physician review under JHP/Inpatient Facility contractual agreement. Create Inpatient Facility appeal in JHP EMR (Electronic Medical Record) system as it correlates with the appropriate member, Inpatient Facility, authorization status, and dates of service. Document appeal processing activities/actions as well as appeal review outcomes in JHP EMR system. Review and confirm all appeal review outcome communications include the correct dates of service, level of care appealed, and next level of appeal contractual timeframe, if applicable. Forward written communication of Inpatient Facility appeal review outcomes to requesting facility documenting actions in JHP EMR system. Coordinate and process P2P (Peer to Peer) discussion requests submitted by facility Physician Advisor, ordering physician, Nurse Practitioner, or Physician Assistant. Communicate P2P requests to JHP Medical Director as well as P2P outcomes to appropriate Medical Management team via JHP EMR system. Maintain communication with P2P requestor, JHP Medical Director, and/or Medical Management team as needed. Education and Experience: High School Diploma required. Minimum 2 years of managed care experience Knowledge of medical terminology. Minimum of 5 years’ experience of EMR experience Minimum of 2 years’ experience of Protected Health Information (PHI) in a HIPAA-compliant manner. Interpersonal skills, strong writing, and verbal skills are required to successfully work cross functionally and externally. Microsoft office suite experience required Agile, deadline-oriented, able to multitask, works well under pressure Work Shift Workday Day (United States of America) Worker Sub Type Regular Employee Entity Health Partners Plans, Inc. Primary Location Address 1101 Market, Philadelphia, Pennsylvania, United States of America Nationally ranked, Jefferson, which is principally located in the greater Philadelphia region, Lehigh Valley and Northeastern Pennsylvania and southern New Jersey, is reimagining health care and higher education to create unparalleled value. Jefferson is more than 65,000 people strong, dedicated to providing the highest-quality, compassionate clinical care for patients; making our communities healthier and stronger; preparing tomorrow's professional leaders for 21st-century careers; and creating new knowledge through basic/programmatic, clinical and applied research. Thomas Jefferson University, home of Sidney Kimmel Medical College, Jefferson College of Nursing, and the Kanbar College of Design, Engineering and Commerce, dates back to 1824 and today comprises 10 colleges and three schools offering 200 undergraduate and graduate programs to more than 8,300 students. Jefferson Health, nationally ranked as one of the top 15 not-for-profit health care systems in the country and the largest provider in the Philadelphia and Lehigh Valley areas, serves patients through millions of encounters each year at 32 hospitals campuses and more than 700 outpatient and urgent care locations throughout the region. Jefferson Health Plans is a not-for-profit managed health care organization providing a broad range of health coverage options in Pennsylvania and New Jersey for more than 35 years. Jefferson is committed to providing equal educational and employment opportunities for all persons without regard to age, race, color, religion, creed, sexual orientation, gender, gender identity, marital status, pregnancy, national origin, ancestry, citizenship, military status, veteran status, handicap or disability or any other protected group or status. Benefits Jefferson offers a comprehensive package of benefits for full-time and part-time colleagues, including medical (including prescription), supplemental insurance, dental, vision, life and AD&D insurance, short- and long-term disability, flexible spending accounts, retirement plans, tuition assistance, as well as voluntary benefits, which provide colleagues with access to group rates on insurance and discounts. Colleagues have access to tuition discounts at Thomas Jefferson University after one year of full time service or two years of part time service. All colleagues, including those who work less than part-time (including per diem colleagues, adjunct faculty, and Jeff Temps), have access to medical (including prescription) insurance. For more benefits information, please click here In keeping with Jefferson's Mission, We Improve Lives, it is our goal to recruit, retain, develop and reward highly-qualified employees. If you are enthusiastic, caring and dedicated to service excellence, we invite you to consider joining Jefferson. Jefferson encourages its employees to expand their knowledge and develop their careers through growth opportunities and continuing education. With a long standing history, Jefferson has been advancing the medical field from the heart of Center City Philadelphia for nearly 200 years. Our Mission, We Improve Lives, expands to every corner of the organization. From our weekly farmer’s market, to our new Jefferson Accelerator Zone for innovation, our employees’ passion for the community is evident by the daily gestures towards our patients, students and each other.