BASIC FUNCTION:Under supervision, this position is responsible for providing support to members, clinicians, and physicians in the processing of Physical Health clinical appeals including responding to inquiries, conducting outbound calls, conducting research, performing data entry, resolving problems by working across departments, and supporting the Physical Health Appeals Department.ESSENTIAL FUNCTIONS:Receive and respond to customer, clinician, or physician inquiries. Process information from member or provider to determine needs/wants and ensure customer/clinician/physician questions have been addressed. Respond or send to appropriate internal party.Distribute physical health appeals to the Appeals clinicians based on assigned parameters.Maintain production requirements based on established department business needs.Provide support to the clinical team by performing the non-clinical functions necessary to generate and close a case within the platform.Responsible for scrubbing appeals in the Enterprise Appeal ApplicationResearch next level of appeal and communicate information to the member, provider, and facility when applicable.Responsible for uploading clinical data to any external review organization if needed.Assign and delegate work items received via email and/or medical management system.Communicate and interact effectively and professionally with co-workers, management, customers, etc.Comply with HIPAA, Diversity Principles, Corporate Integrity, Compliance Program policies and other applicable corporate and departmental policies.Maintain complete confidentiality of company business.Maintain communication with management regarding development within areas of assigned responsibilities and perform special projects as required or requested.JOB REQUIREMENTS:1 or 2 years college OR 3 years of experience with automated systems. Experience coordinating member needs, providing assistance to members, and analyzing member needs. Knowledge of medical terminology. Database experience or PC applications experience. Customer service skills. Verbal and written communications skills including interpersonal skills to assist members and coordinate care with physician offices, developing written correspondence to members and to other department personnel, and to support departmental personnel and functions.Notes:RemoteContract to Hire
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