STAR+PLUS Appeals Coordinator

Internal Number: 173068

JOB SUMMARY

The STAR+PLUS Appeals Coordinator is responsible for intake of all forms of correspondence for the medical appeals team to process for medical appeals, post service claim and medical appeal that are assigned to a nurse to facilitate medical necessity review. This position is responsible for the accurate recording of all provider data elements into a database.

JOB SPECIFICATIONS
Essential Functions

• Reviews the documentation received for timeliness of requests. Data entry of all provider appeals, Fair Hearings, IROs and claim appeal inquiries into the appeals database ensuring accurate recording of all provider data elements.
• Data entry of provider appeals, retrospective reviews, and inquiries received in appeals department and preparation of documents for laserfiche and scanning as warranted.
• Maintains an accurate data base of all appeals and tracks responses due, correctly identify the type of review such as adverse determination, LOC, MN, DRG and DOS.
• Daily monitoring and effective follow-up of provider claim appeals and inquiries to ensure closure within 30 days of receipt.
• Demonstrates Harris Health and Community Health Choice values, including trust, integrity, mutual respect, diversity, responsiveness and caring service.
• Actively contributes to achievement of departmental goals, as identified in Department?s annual business plan, including specific departmental process improvement plans.
• Other duties as assigned.

MINIMUM QUALIFICATIONS:

• Education/Specialized Training/Licensure: High School Diploma or Equivalent required.
• Work Experience (Years and Area): Two (2) years insurance related job experience. 1 Star+Plus experience.
• Medical terminology or medical assistant experience preferred.
• 1-3-year Star Plus Experience minimum preferred.
• Software Proficiencies: Microsoft Office (Word, Excel, Outlook)