Description:
It's a great time to put the strength of Coventry Health Care behind your career! Coventry is currently recruiting for projected openings in our Coventry Health Care of Missouri health plan related to our anticipated entrance into the Government health insurance exchange program. Start dates will be in the fall, once participation in the exchanges is approved by the Government.
Coventry Health Care provides a full range of risk and fee-based managed care products and services to a broad cross section of employer and government-funded groups, government agencies, and other insurance carriers and administrators.
GENERAL SUMMARY
The Clinical Appeals Coordinator is responsible for coordinating grievance appeals activity and ensuring compliance with State and Federal regulations and accrediting bodies.
ESSENTIAL RESPONSIBILITIES
- Responsible for reviewing correspondence from members requesting to file a grievance. Coordinates a response to the member in compliance with all specified timeframes.
- Responsible for coordinating the collection of all information and the presentation to the Medical Director/Appeals Committee.
- Handles complex clinical appeals such as transplants.
- Works closely with Medical Directors on clinical issues to ensure comprehensive appeal investigations.
- Coordinates outside physician clinical reviews.
- Responsible for ensuring that all timeframes throughout the appeals process are met.
- Researches member information in response to difficult inquiries, including but not limited to authorizations, payments, denials, coordination of benefits.
- Works closely with Health Services contact in obtaining clinical information of appeals for denial of services.
- Assesses, investigates, and resolves difficult issues to achieve member satisfaction.
- Performs other duties as required.
Qualifications:
JOB SPECIFICATIONS
- Clinical licensure required based on clinical sector supported.
- General Appeals requires current LPN or RN license in state where job duties are performed.
- Behavioral Health Medical Management requires professional licensure in state where job duties are performed; Licensed Clinical Social Worker (LCSW), Licensed Marriage and Family Therapist (LMFT), Licensed Mental Health Counselor (LMHC), Licensed Master Social Worker (LMSW), Licensed Professional Counselor (LPC) , licensed psycholgist, or Registered Nurse (RH).
- Bachelor's degree or equivalent experience.
- Experience in processing and working with all types of products including HMO, PPO, and Indemnity under both fully insured and self-funded arrangements.
- Previous (1-2 years) customer service experience preferred.
- Medical terminology and computer skills required.
- Experience processing and working with appeals preferred.
- Effective communication skills required.Coventry Health Care is an Affirmative Action/Equal Opportunity Employer, and we are committed to building a talented and diverse team.
Job: Professionals
Primary Location: St. Louis, MO, US
Other Locations: Champaign-Illinois-United States,
Organization: 24000 - CHC of Missouri
Schedule: Full-time
Job Posting: 2013-08-21 00:00:00.0
Job ID: 1312656
It's a great time to put the strength of Coventry Health Care behind your career! Coventry is currently recruiting for projected openings in our Coventry Health Care of Missouri health plan related to our anticipated entrance into the Government health insurance exchange program. Start dates will be in the fall, once participation in the exchanges is approved by the Government.
Coventry Health Care provides a full range of risk and fee-based managed care products and services to a broad cross section of employer and government-funded groups, government agencies, and other insurance carriers and administrators.
GENERAL SUMMARY
The Clinical Appeals Coordinator is responsible for coordinating grievance appeals activity and ensuring compliance with State and Federal regulations and accrediting bodies.
ESSENTIAL RESPONSIBILITIES
- Responsible for reviewing correspondence from members requesting to file a grievance. Coordinates a response to the member in compliance with all specified timeframes.
- Responsible for coordinating the collection of all information and the presentation to the Medical Director/Appeals Committee.
- Handles complex clinical appeals such as transplants.
- Works closely with Medical Directors on clinical issues to ensure comprehensive appeal investigations.
- Coordinates outside physician clinical reviews.
- Responsible for ensuring that all timeframes throughout the appeals process are met.
- Researches member information in response to difficult inquiries, including but not limited to authorizations, payments, denials, coordination of benefits.
- Works closely with Health Services contact in obtaining clinical information of appeals for denial of services.
- Assesses, investigates, and resolves difficult issues to achieve member satisfaction.
- Performs other duties as required.
Qualifications:
JOB SPECIFICATIONS
- Clinical licensure required based on clinical sector supported.
- General Appeals requires current LPN or RN license in state where job duties are performed.
- Behavioral Health Medical Management requires professional licensure in state where job duties are performed; Licensed Clinical Social Worker (LCSW), Licensed Marriage and Family Therapist (LMFT), Licensed Mental Health Counselor (LMHC), Licensed Master Social Worker (LMSW), Licensed Professional Counselor (LPC) , licensed psycholgist, or Registered Nurse (RH).
- Bachelor's degree or equivalent experience.
- Experience in processing and working with all types of products including HMO, PPO, and Indemnity under both fully insured and self-funded arrangements.
- Previous (1-2 years) customer service experience preferred.
- Medical terminology and computer skills required.
- Experience processing and working with appeals preferred.
- Effective communication skills required.Coventry Health Care is an Affirmative Action/Equal Opportunity Employer, and we are committed to building a talented and diverse team.
Job: Professionals
Primary Location: St. Louis, MO, US
Other Locations: Champaign-Illinois-United States,
Organization: 24000 - CHC of Missouri
Schedule: Full-time
Job Posting: 2013-08-21 00:00:00.0
Job ID: 1312656