Appeals Coordinator


Durham, North Carolina

17 days ago

Similar Jobs

Job Description

Title: Appeals Coordinator
Duration: 6 months
Training Hours: 8am- 5pm EST.
Hours after training can vary between: 7am-6pm, flexibility to stagger but all hours must be covered by staff.
Alabama, Arizona, Arkansas, Colorado, Florida, Georgia, Idaho, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maryland, Michigan, Mississippi, Missouri, North Carolina, Ohio, Oklahoma, Pennsylvania, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, Wisconsin, and Wyoming.

  • Responsible for the initial assessment, review, and determination of the validity of an appeal and/or grievance type for all cases coming into the department.. Uses critical thinking and decision making to correctly identify and assign the appeal/grievance type to ensure compliance with the regulations outlined by the North Carolina Department of Insurance (NCDOI), the National Committee for Quality Assurance (NCQA), the Department of Labor (ERISA) and the Centers for Medicare and Medicaid Services (CMS). Responsible for determining the appropriate response based on the type of case from the initial research performed. Communicate receipt of the case with internal and external stakeholders including but not limited to members, physicians, attorneys, etc. within the prescribed regulatory/accreditation timeframe to ensure compliance. Responsible for initiating the initial research on the appeal/grievance from the numerous systems to ensure all data is captured for entry into the appeals and grievances system. Participates in identification, problem solving, and improvements in product design, policies and processes affecting Member Rights and Appeals. The Resolution Coordinator is also the forefront of any incoming correspondence to the Appeals unit. This person is responsible for setting the pace of the workflow within the unit.
  • Performs initial research and documentation of all incoming appeals and, grievances. Demonstrates the ability to research benefits, Plan policies, provider contracts, and determine the appropriate time frames applicable to an incoming request
  • Determines the validity of all incoming appeals and makes critical decisions to keep and work as a valid appeal or send letter back to requestor indicating the appeal is non-valid and provide rationale for the non-valid decision. Provide member education regarding appropriate submission of inquiries.
  • Provides mandated written responses to appellants of receipt of appeal, need for additional information and may provide interim responses giving notice of an extension of the appeals process to unforeseen delays, (i.e.) Acknowledgement letters and 3rd party authorizations forms, Appointment Of Representative and Waiver Of Liability forms.
  • Researches all department requests, set up, and assign cases, as well as maintain files within the unit
  • Identifies all misrouted inquiries and handles accordingly
  • Provides direct feedback to Appeals Department management for identified problems
  • Identifies additional tasks and works independently to ensure all up front functions run smoothly, which may include scanning and imaging as required, answer member/provider questions via incoming telephone calls in a professional quality driven manner
  • Analyzes and coordinates all aspects of the appeals process to ensure compliance with our medical necessity criteria, Corporate Medical Policy, contract provisions, NC DOI, legislative and NCQA requirements
  • Sorts, and distributes all incoming request via direct mail, right fax and Macess in a timely efficient manner throughout the day to ensure regulatory filing requirements are met
  • Date stamp and initial all incoming correspondence via direct mail
Hiring Requirements
  • Associates degree with 1 year Healthcare Customer Service or claims experience OR
  • High School Graduate or GED with
  • 2 years of Healthcare Customer Service or claims experience handling inquiries and/or claims processing OR
  • 12 months experience in the Appeals department
  • Knowledge of company products and systems, (claims system and ASO, underwritten, individual SHP and Medicare member benefits). Able to read and understand claims history, denials, payments, and suspends, and hold codes.

About Us: Established in 2004, SPECTRAFORCE® is one of the largest and fastest-growing diversity-owned staffing firms in the US. The growth of our company is a direct result of our global client service delivery model that is powered by our state-of-the-art A.I. proprietary talent acquisition platform, robust ISO 9001:2015/ISO 27001 certified processes, and strong and passionate client engaged teams. We have built our business by providing talent and project-based solutions, including Contingent, Permanent, and Statement of Work (SOW) services to over 140 clients in the US, Canada, Puerto Rico, Costa Rica, and India. Key industries that we service include Technology, Financial Services, Life Sciences, Healthcare, Telecom, Retail, Utilities and Transportation. SPECTRAFORCE is built on a concept of “human connection,” defined by our branding attitude of NEWJOBPHORIA®, which is the excitement of bringing joy and freedom to the work lifestyle so our people and clients can reach their highest potential. Learn more at:
Benefits: SPECTRAFORCE offers ACA compliant health benefits as well as dental, vision, accident, critical illness, voluntary life, and hospital indemnity insurances to eligible employees. Additional benefits offered to eligible employees include commuter benefits, 401K plan with matching, and a referral bonus program. SPECTRAFORCE provides unpaid leave as well as paid sick leave when required by law.

Equal Opportunity Employer: SPECTRAFORCE is an equal opportunity employer and does not discriminate against any employee or applicant for employment because of race, religion, color, sex, national origin, age, sexual orientation, gender identity, genetic information, disability or veteran status, or any other category protected by applicable federal, state, or local laws. Please contact Human Resources at if you require reasonable accommodation. 
At SPECTRAFORCE, we are committed to maintaining a workplace that ensures fair compensation and wage transparency in adherence with all applicable state and local laws. This position’s starting pay is: $23.25/monthly.

Similar Jobs