Appeals & State Hearings Coordinator

Caresource Indianapolis , IN 46218

Posted 2 months ago

Role and Responsibility:

  • Responsible for the completion of pharmacy and dental appeals

  • In collaboration with the Quality Improvement Manager and Operations Team Lead will be responsible for all daily appeals processing and processing and coordination of all State Hearings

  • Responsibilities are completed while ensuring regulatory compliance and HIPPA guidelines are met for Medicaid, Medicare and future lines of business

  • Review and complete filing of all dental and pharmacy appeals within appropriate time frames

  • Retrieve pharmacy documentation from RX Approver

  • Document pharmacy appeals in Facets

  • Request medical/dental records from providers

  • Forward cases to the dental reviewer / pharmacist for review and determination

  • Prepare all member appeals and forward to the Clinical Appeals nurse once the information is received

  • Pull member denial charts from Medical Management

  • Retrieve radiology documentation from RadMD

  • Document radiology appeals in Facets

  • Log, investigate, schedule and prepare State Hearings for the Clinical Appeals Nurse

  • Complete appeal and State Hearing files to be ready for filing

  • Mail all department letters related to appeals and State Hearings

  • Provide support to the department, including filing, printing, copying, including the preparation of new appeal and State Hearing files

  • Track UPS mail delivery to appropriate parties to ensure timeframes and regulatory guidelines are met

  • Track timeliness of member appeals and request an extension from the Grievance and Appeals Specialist if necessary to ensure timeframes are met

  • Track appeals daily/monthly and report at Appeals meetings

  • Interact with other departments such as Medical Management, Pharmacy and Grievance and Appeals

  • Examine and identify ways to improve existing processes/workflows

  • Maintain chart storage

  • Perform any other job related functions as requested


Education / Experience:

  • High School Diploma or equivalent required

  • Associate Degree preferred

  • Minimum of one (1) year of customer service, healthcare administration/management, or grievance and appeals experience required

  • Managed Care experience preferred

Required Competencies / Knowledge /

  • Ability to analyze information

  • Communication skills

  • Ability to work independently and within a team environment

  • Excellent communication skills (both written and verbal) and ability to work with multi-disciplinary departments across the organization

  • Effective organizational and prioritization skills

  • Ability to manage time effectively

  • Attention to detail

  • Proper grammar usage

  • Critical listening and thinking skills

  • Proper phone etiquette

  • Customer service oriented

  • Decision making/problem solving

  • Change resiliency

  • Ability to accurately communicate summary information in a written format

  • Intermediate computer skills; Microsoft Word, Excel and Access

Licensure / Certification:

  • None

Working Conditions:

  • General office environment; may be required to sit/stand for long periods of time

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Appeals & State Hearings Coordinator