Appeals Assistant

POSITION SUMMARY: The Appeals Assistant: Responsible for ensuring professional handling of all provider appeals in a timely, compliant, and efficient way as well as be responsible for the daily office operations, procedures, and resources to facilitate organizational effectiveness and efficiency.

REPORTS TO: Compliance Appeals Manager

SUPERVISES: None

QUALIFICATIONS:

Education: High School Diploma; Associate’s degree or equivalent experience in health care, conflict resolution, or related field preferred.

Experience: A minimum of 1 year of experience in a medical office setting is recommended

Core Competencies: Ability to operate independently and within a team environment. Good communication skills, problem analysis and assessment, work and time management, computer skills and use of information systems (Excel, Word, etc), organizational skills and an orientation to deadlines and details. Diligent about follow-through, thorough and well-prepared. Ability to responds well under pressure.

Other: Valid driver’s license and auto insurance.

FUNCTIONS AND RESPONSIBILITIES:

1. Under the direction of the assigned supervisor, perform a variety of clerical duties pertaining to the compliance and appeals department.

2. Participate in chart reviews and audits.

3. Maintain a current knowledge of federal and state regulations, as well as payer specific requirements and take appropriate action as appropriate.

4. Manage the receipt, investigation, and resolution of appeals in a timely, compliant, and highly effective manner.

5. Receives and performs research on appeals and categorizes each appeal appropriately.

6. Communicate with providers in a professional manner, and clearly articulates what information is required for processing appeals.

7. Completes data entry and documentation requirements in multiple systems: including correct input of audit universe fields.

8. Coordinates with internal departments and external vendors relative to the investigation, review and resolution of an appeal and the research needed to prepare the case for internal and external review.

9. Interacts with Managers, Medical Directors, Executive Directors, Case Managers, Legal, Finance, and other areas in facilitating identification and resolution of appeals.

10. Assisting with the inner office departments including medical records, human resources, Quality Assurance, or front desk as needed.

11. Perform clerical, administrative, and secretarial responsibilities and tasks within the office.

12. Monitor, transfer, and guide all telephonic communications to needed departments.

13. Allocation of resources to enable task performance.

14. Opening, distributing, and managing the mail as needed.

15. Maintaining a clean office work environment, including wiping down counters, doors, and taking out trash if necessary.

16. Design, implement and ensure that the policies and procedures are created and are adhered to.

17. Maintain a safe and secure working environment.

18. Fax, record, and monitor paperwork that is faxed in and out of the office.

19. All other duties and responsibilities as assigned.