Appeals Coordinator

The Appeals Coordinator is responsible for providing expertise in reviewing, researching, investigating, negotiating, and resolving both verbal & written appeals and grievances from members and providers within stringent time frames.

Responsibilities

Appeals and Grievances

• Gain and maintain the understanding of the plan designs and effectively apply that knowledge.
• Maintain a comprehensive working knowledge of Policies, Procedures, Compliance Regulations, Schedule of Benefits and turnaround times across all product lines.
• Maintain an understanding of claims processing and an ability to research claims issues.
• Prepare acknowledgment and response letters to members and providers.
• Maintain case records on all complaints, grievances, and appeals.
• Identify, research and resolve claim disputes received from a variety of sources.
• Ability to multitask on multiple appeals simultaneously, prioritizing work and completing within stringent time frames.
• Prepare statistical analysis for required reporting.
• Analyze and track trends.

Teamwork

• Work cooperatively with other team members
• Actively participate in team meetings and training activities.
• Perform additional responsibilities and projects as periodically assigned.

Education/Certification:

• High School Diploma/GED
• Minimum of five (5) years of experience with coding certification

Skills/Abilities:

• Prior grievance and appeals experience preferred.
• Extensive knowledge of medical terminology, CPT Codes, ICD 9/10 and medical claim forms.
• Strong analytical and research skills with the ability to read and assess medical documentation and draw valid conclusions.
• Proficiency in interpretation of plan documents.
• Solid knowledge of MS Excel & MS Word.
• Minimum 40 WPM and 3,000 KPH proficiency
• Strong mathematical skills required
• Professional, client-focused approach to colleagues and assignments.
• Strong oral and written communication skills with exceptional attention to details.
• Ability to seek out experiences that may change perspective or provide an opportunity to learn new things.
• Strong dedication to follow-through on all tasks and assignments.
• Ability to organize, set priorities, work independently and complete multiple projects within established deadlines.
• Ability to sit for long periods of time operating a computer keyboard.
• Bilingual in English and Spanish a plus.

Employee Benefits Program

COMPANY PROVIDES:

• MEDICAL, DENTAL, VISION
• SHORT-TERM DISABILITY
• Full coverage benefits for a low weekly premium of $5 (Employee Only), $15 (for Child(ren) and $20 per week for full family or Employee/Spouse.
• COMPANY PAID supplemental dental coverage of $1,000 per year for Employee.
• COMPANY PAID LONG TERM Disability & Life/AD&D coverage.
• 401K Plan including company match up to 5%.
• COMPANY PAID additional pension plan entirely funded by the company.
• EXCEPTIONAL TIME OFF package including Paid Personal Leave (PPL) and Vacation with annual BUY BACK options!!!!
• Annual, automatic pay increases.

Southwest Service Administrators provides equal employment opportunities (EEO) to all employees and applicants for employment without regard to race, color, religion, sex, national origin, pregnancy, military and veteran status, age, physical and mental disability, genetic characteristics, or any other considerations made unlawful by applicable state or local laws. This policy applies to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence compensation and training. Southwest Service Administrators expressly prohibits any form of workplace harassment based on race, color, religion, sex, national origin, pregnancy, military and veteran status, age physical and mental disability, or genetic characteristics.