The Appeals Coordinator serves to administrate the Appeals and Grievance process as outlined in the Plan Member Handbook/Evidence of Coverage, departmental policies and procedures, and regulatory standards. This role requires expertise and strong working knowledge of CMS guidelines, NCQA standards and other applicable regulatory requirements. The Coordinator serves as a liaison between Members and the Plan with appeals regarding denied claims/services, referrals, membership and benefit issues and concerns regarding quality of care or service. The Coordinator is responsible for presentation of the Member appeal to the Plan Medical Staff and Center for Medicare/Medicaid Services (GOLD line of business) contracted reviewer, and the Plan contracted external review agency in accordance with applicable laws, organizational policies, and regulatory requirements. Through research, documentation, and corrective action planning must be established for each respective case.
Works under the direct supervision of the Director, Appeals & Grievances.
Competencies and Skills:
Demonstrates strong work ethic, dependable and proactive required.
Excellent communication, writing and interpersonal skills required.
Proficiency with Microsoft Office applications including but not limited to, Word, Excel databases and keyboard proficiency required.
Demonstrates the ability to work independently to prepare and present projects required.
Demonstrates the ability to multi-task and problem solve required
Education and or Experience:
BS or BA degree in communications, business, health care or related field with one-year related work experience required.
OR Associate degree with two-year work experience in related field required.
OR Minimum of five (5) years in customer service or other equivalent managed care experience required.
Paralegal certification preferred.
Knowledge of Insurance Operations / Managed Health Care delivery strongly preferred.
Working Conditions/Physical Demands:
Work is typically performed in an office environment. Independent travel to the sites
throughout the system and surrounding communities may be required.
OUR PURPOSE & VALUES: Everything we do is about caring for our patients, our members, our students, our Geisinger family and our communities. KINDNESS: We strive to treat everyone as we would hope to be treated ourselves. EXCELLENCE: We treasure colleagues who humbly strive for excellence. LEARNING: We share our knowledge with the best and brightest to better prepare the caregivers for tomorrow. INNOVATION: We constantly seek new and better ways to care for our patients, our members, our community, and the nation.
ABOUT GEISINGER: Geisinger is a physician-led health system comprised of approximately 30,000 employees, including nearly 1,600 employed physicians, 13 hospital campuses, two research centers, and a 583,000-member health plan Geisinger is nationally recognized for innovative practices and quality care. Geisinger serves more than 3 million people in central, south-central and northeast Pennsylvania and also in southern New Jersey with the addition of National Malcolm Baldridge Award recipient AtlantiCare, A member of Geisinger. In 2017, the Geisinger Commonwealth School of Medicine became the newest member of the Geisinger Family.
We offer healthcare benefits for full time and part time positions from day one, including vision, dental and domestic partners.* Perhaps just as important, from senior management on down, we encourage an atmosphere of collaboration, cooperation and collegiality. For more information, visit www.geisinger.org, or connect with us on Facebook, Instagram, LinkedIn and Twitter.
** Does not qualify for J-1 waiver. We are an Affirmative Action, Equal Opportunity Employer Women and Minorities are Encouraged to Apply. All qualified applicants will receive consideration for employment and will not be discriminated against on the basis of disability or their protected veteran status.
*Domestic partner benefits not applicable at Geisinger Holy Spirit.
At Geisinger, our innovative ideas are inspired by the communities we serve – like our Fresh Food
Farmacy, a program that delivers life-saving healthy alternatives to patients with diabetes. With additional tools like our MyCode Community Health Initiative, one of the first health system genome sequencing
programs, and our new asthma app suite that we developed in partnership with AstraZeneca, it’s no wonder we’re ranked one of the Top 5 Most Innovative Healthcare Systems by Becker's Hospital Review. We continually work towards continuous improvement in a culture where everyone has a voice and firmly believe that better begins with all of us.
Founded more than 100 years ago, Geisinger serves more than three million residents throughout central, south-central and northeastern Pennsylvania and southern New Jersey. Our physician-led system is comprised of 30,000 employees, including 1,600 employed physicians, and consists of 13 hospital campuses, the Geisinger Health Plan, Geisinger Commonwealth School of Medicine and two research centers.
What you do at Geisinger shapes the future of health and improves lives – for our patients, communities, and you.