Estimated Travel: {{ getCommuteTime(details) }} minutes.
{{ getCustomAttribute( details.job, 'city_admin1_country')}}
Lead Appeal Coordinator
Job Title
Lead Appeal Coordinator
Duration
Open until filled
Description
Let’s do great things, together!
About Moda
Founded in Oregon in 1955, Moda is proud to be a company of real people committed to quality. Today, like then, we’re focused on building a better future for healthcare. That starts by offering outstanding coverage to our members, compassionate support to our community and comprehensive benefits to our employees. It keeps going by connecting with neighbors to create healthy spaces and places, together. Moda values diversity and inclusion in our workplace. We aim to demonstrate our commitment to diversity through all our business practices and invite applications from candidates that share our commitment to this diversity. Our diverse experiences and perspectives help us become a stronger organization. Let’s be better together.
Position Summary
Analyze appeal data and develop reports following the technical specifications for reporting to accrediting and regulatory organizations, client groups, healthcare organization partners, and quality improvement committees. Provide back up for the Appeals Supervisor. Assist the supervisor in developing new and established appeal coordinators, to ensure best practices in grievance and appeal processing. Assist supervisor in special projects and assignments and participate in the recruitment of new staff. This is a FT WFH role.
Pay Range
$25.08- $28.21 hourly (depending on experience)
**Actual pay is based on qualifications. Applicants who do not exceed the minimum qualifications will only be eligible for the low end of the pay range.
Please fill out an application on our company page, linked below, to be considered for this position.
https://j.brt.mv/jb.do?reqGK=27755413&refresh=true
Benefits:
Medical, Dental, Vision, Pharmacy, Life, & Disability
401K- Matching
FSA
Employee Assistance Program
PTO and Company Paid Holidays
Required Skills, Experience & Education:
College degree or equivalent work experience.
At least 2 years of experience as an Appeal Coordinator.
1 – 2 years of experience as a Sr Claim Support Specialist or Customer Service Rep.
Strong understanding of appeal utilization management and claims processing and administration workflows, ability to plan training for new appeal programs and projects, and measure compliance with state and federal requirements as well as with accreditation standards.
Understand large group and individual healthcare insurance dynamics and provisions, including funding types, benefit designs, stop loss and underwriting as well as Moda Health/ODS benefit administration policies.
Ability to instruct, motivate, direct individuals at various skill levels.
Working knowledge of accrediting standards and state and federal laws, governing member appeals.
Project management skills. Ability to track and coordinate multiple projects and meet timelines.
Strong analytical, problem-solving, and decision-making skills.
Ability to be effective in managing information flow in a fast-paced dynamic team environment; interact with all levels of management and prioritize and manage multiple tasks, projects, and deadlines. Self-directed and flexible.
Demonstrated strong verbal, writing and interpersonal communication skills.
Experience in maintaining, troubleshooting, and manipulating databases.
Adept in Microsoft Office Suite with strong Microsoft Excel and Access skills. Experience in basic query methods.
Ability to maintain confidentiality and projects a professional business image.
10 key proficiency of 100 kspm net on a computer numeric keypad.
Type a minimum of 25 wpm net on a computer keyboard.
Primary Functions:
Analyze, interpret, and report appeal and grievance data to facilitate internal and external customer understanding of the reports and the impact to them. Evaluate significant and persistent claims issues for process improvement opportunities.
Collaborate with the Appeal supervisor to engage the appeal team of other departments in resolution of issues by taking corrective action. Monitor the effectiveness of corrective action with ongoing analysis appeal and grievance data.
Consults with internal and external customers to define grievance and appeal report requirements, develop technical specifications and design reports.
Build queries to extract data from the Access databases and other data sources. Ensure grievance and appeal reporting comply with the standards of state and federal regulatory agencies as well as that of accreditation entities.
Prepare and present appeal and grievance reports for quality committees and client groups. Interact with internal departments to ensure groups receive consistent, timely information. Provide ongoing customer support for existing reports.
Monitor data entry of member appeals into databases and perform quality checks to ensure accuracy in grievance and appeal reports.
Back up for the Appeal Supervisor. Assist supervisor to develop new and established appeal coordinators to ensure best practice in grievance and appeal processing. Assist supervisor in special projects and assignments and participate in the recruitment of new staff.
Perform systems training and retraining for appeal staff.
Train and coach new and established appeal staff on the processing for all appeal roles, lines of business and products.
Collaborate with supervisor on development of training materials and updates of policies and procedures.
Coordinate appeal workflows and make daily staffing assignments.
Audit acknowledgement and appeal final resolution letters.
Pull case files for the monthly Medicare Compliance audits. Review audit findings for process improvement and training.
Pull case files for monthly Part C and Part D audits, perform the audits, document results and report findings to Appeal leadership and staff.
Assume the lead role in developing the grievances and appeal report for the organization’s annual quality evaluation.
Ensure compliance with applicable state, federal and accrediting member appeal utilization management standards, quality assurance and quality improvement standards. Prepare for and participate in audits and reviews by external organizations, including the National Committee for Quality Assurance, coordinated care organizations, quality improvement organizations, the Centers for Medicaid and Medicare Services, the Oregon Health Authority and state insurance divisions.
Provides appeal and complaint input for the requests for proposals (RFP’s).
Complete ad hoc request as assigned.
Seek out and participate in growth and development activities.
Other duties as assigned.
Working Conditions & Contact with Others
Office environment with extensive close PC and keyboard work, constant sitting, and phone work. Must be able to navigate multiple screens. Work in excess of 40 hours per week, including evenings and occasional weekends, to meet business need.
Inside the company with all departments. Outside the company with state insurance divisions, provider offices, members, attorneys, quality assurance auditors, state and federal auditors, health plan accrediting bodies.
Together, we can be more. We can be better.
Moda Health seeks to allow equal employment opportunities for all qualified persons without regard to race, religion, color, age, sex, sexual orientation, national origin, marital status, disability, veteran status or any other status protected by law. This is applicable to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absences, compensation, and training.
For more information regarding accommodations, please direct your questions to Kristy Nehler & Danielle Baker via our humanresources@modahealth.com email.