Description:
GENERAL SUMMARY
Responsible for coordinating behavioral health appeals and retrospective review activities and ensuring compliance with state and federal regulations and accrediting bodies.
ESSENTIAL RESPONSIBILITIES
- Collects, organizes, and tracks information to facilitate and timely process delegated member and provider appeals and retrospective reviews, using all approved systems, databases and processes required.
- Reviews appeal to determine additional documentation needed to make an appropriate decision. Contacts providers, facilities and/or members as needed to request information or more detailed explanation of services rendered.
- Researches administrative or non-clinical aspects of the appeal or retrospective review request.
- Researches member and provider/facility information in response to difficult inquiries, including, but not limited to, authorizations, payments, denials, coordination of benefits. Resolves difficult issues to achieve member satisfaction.
- Redirects issues as needed to other departments for requests that may not be resolved through appeals or retrospective review process.
- Prepares files for review by the appropriate Medical Director and/or Appeals Supervisor. Staffs cases as needed and timely responds to inquiries from reviewers for further research.
- Ensures all timeframes are met throughout the appeal and retrospective review process.
- Accurately prepares and timely sends required forms, letters, and all other documents required for processing of appeal and retrospective review requests.
- Works closely with utilization, clinical, administrative, claims, and other staff to obtain clinical and administrative information needed to research and process appeal and retrospective review requests.
- Participates in meetings and assists in review of processing and outcome reports to respond to individual questions related to appeals and retrospective review data.
- Assists in identification of quality improvement opportunities and reporting of same to Appeals Supervisor.
- Performs other duties as required.
Qualifications:
JOB SPECIFICATIONSHigh school degree, GED or equivalent experience required.
Some college preferred.
Minimum 2 years experience in customer service and/or claims processing required.
Minimum 2 years experience processing and working with all types of insurance products including HMO, PPO, and Indemnity under both fully insured and self-funded arrangements.
Strong verbal and written communication skills required.
Minimum 1 year experience working with computer systems required, including MSOffice Suite.
Strong organizational skills necessary.
Knowledge of mental health terminology preferred.
Coventry Health Care is an Affirmative Action/Equal Opportunity Employer, and we are committed to building a talented and diverse team.
Job: Administrative Support Workers
Primary Location: Louisville, KY, US
Other Locations: ,
Organization: 51000 - MHNet Specialty Services, LLC
Schedule: Full-time
Job Posting: 2013-06-27 00:00:00.0
Job ID: 1312128
GENERAL SUMMARY
Responsible for coordinating behavioral health appeals and retrospective review activities and ensuring compliance with state and federal regulations and accrediting bodies.
ESSENTIAL RESPONSIBILITIES
- Collects, organizes, and tracks information to facilitate and timely process delegated member and provider appeals and retrospective reviews, using all approved systems, databases and processes required.
- Reviews appeal to determine additional documentation needed to make an appropriate decision. Contacts providers, facilities and/or members as needed to request information or more detailed explanation of services rendered.
- Researches administrative or non-clinical aspects of the appeal or retrospective review request.
- Researches member and provider/facility information in response to difficult inquiries, including, but not limited to, authorizations, payments, denials, coordination of benefits. Resolves difficult issues to achieve member satisfaction.
- Redirects issues as needed to other departments for requests that may not be resolved through appeals or retrospective review process.
- Prepares files for review by the appropriate Medical Director and/or Appeals Supervisor. Staffs cases as needed and timely responds to inquiries from reviewers for further research.
- Ensures all timeframes are met throughout the appeal and retrospective review process.
- Accurately prepares and timely sends required forms, letters, and all other documents required for processing of appeal and retrospective review requests.
- Works closely with utilization, clinical, administrative, claims, and other staff to obtain clinical and administrative information needed to research and process appeal and retrospective review requests.
- Participates in meetings and assists in review of processing and outcome reports to respond to individual questions related to appeals and retrospective review data.
- Assists in identification of quality improvement opportunities and reporting of same to Appeals Supervisor.
- Performs other duties as required.
Qualifications:
JOB SPECIFICATIONSHigh school degree, GED or equivalent experience required.
Some college preferred.
Minimum 2 years experience in customer service and/or claims processing required.
Minimum 2 years experience processing and working with all types of insurance products including HMO, PPO, and Indemnity under both fully insured and self-funded arrangements.
Strong verbal and written communication skills required.
Minimum 1 year experience working with computer systems required, including MSOffice Suite.
Strong organizational skills necessary.
Knowledge of mental health terminology preferred.
Coventry Health Care is an Affirmative Action/Equal Opportunity Employer, and we are committed to building a talented and diverse team.
Job: Administrative Support Workers
Primary Location: Louisville, KY, US
Other Locations: ,
Organization: 51000 - MHNet Specialty Services, LLC
Schedule: Full-time
Job Posting: 2013-06-27 00:00:00.0
Job ID: 1312128