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appeals Coordinator
4 months ago
City/State
Glen Allen, VA
Overview
Work Shift
First (Days) (United States of America)
Sentara Health is currently seeking a Full-Time Appeals
Coordinator in the Glen Allen or Richmond, VA area.
Position is hybrid remote and may require 2-3 days a week in the office.
Weekend rotation may be required for one Saturday per month.
The Appeals Coordinator is responsible for the investigation and documentation of member appeals and grievances in compliance with State law, applicable rules and regulations and provider and group agreements. Works closely with the Plan's Medical Directors who are responsible for all decision regarding clinical appeals/ grievances and the Appeals Manager who is responsible for non-clinical appeals and grievances.
* Gathers clinical information for appeals and grievances by using established criteria
* Prepares reviews for cases that do not meet the required criteria to be sent to a clinician for review
* Coordinate and deliver verbal and written information for appeals and grievances
* Composes decision letters for appeals using contractual requirements and standards set forth by the National Committee for Quality Assurance (NCQA)
* Maintains files and logs related to all appeals and grievances
* Coordinates appeal hearings with appropriate agencies
Job Requirements
* High School Grad or Equivalent
* Managed Care Experience 3 years
* Microsoft Word, Microsoft Excel, Microsoft Access required
Sentara Health Plans provides health insurance coverage through a full suite of commercial products including consumer-driven, employee-owned and employer-sponsored plans, individual and family health plans, employee assistance plans, and plans serving Medicare and Medicaid enrollees.
With more than 30 years' experience in the insurance business and 20 years' experience serving Medicaid populations, we offer programs to support members with chronic illnesses, customized wellness programs, and integrated clinical and behavioral health services - all to help our members improve their health.
Benefits: Sentara offers an attractive array of full-time benefits including Medical, Dental, Vision, Paid Time Off, Sick, Tuition Reimbursement, a 401k/403B with matching funds, 401a, Performance Plus Bonus, Career Advancement Opportunities, Work Perks, and more.
Along with competitive salary we also offer the following benefits:
Adoption, Infertility, and Surrogacy Reimbursement
Educational Assistance Programs, including Tuition Assistance
Emergency Back-Up Care
Financial Wellness Tools, including extra student debt payments on your student loans.
Medical, Dental, and Vision Benefits
Paid Annual Leave (PAL)
Paid Parental Leave
Our success is supported by a family-friendly culture that encourages community involvement and creates unlimited opportunities for development and growth.
Be a part of an excellent healthcare organization that cares about our People, Quality, Patient Safety, Service, and Integrity. Join a team that has a mission to improve health every day and a vision to be the healthcare choice of the communities that we serve
keywords: appeals, grievances, coordinator, managed care, health plan
Job Summary
The Appeals Coordinator is responsible for the investigation and documentation of member appeals and grievances in compliance with State law, applicable rules and regulations and provider and group agreements. Works closely with the Plan's Medical Directors who are responsible for all decision regarding clinical appeals/ grievances and the Appeals Manager who is responsible for non-clinical appeals and grievances.
Qualifications:
HS - High School Grad or Equivalent (Required)
Managed Care
Skills
Microsoft Access, Microsoft Excel, Microsoft Word
Sentara Healthcare prides itself on the diversity and inclusiveness of its close to an almost 30,000-member workforce. Diversity, inclusion, and belonging is a guiding principle of the organization to ensure its workforce reflects the communities it serves.
Per Clinical Laboratory Improvement Amendments (CLIA), some clinical environments require proof of education; these regulations are posted at ecfr.gov for further information. In an effort to expedite this verification requirement, we encourage you to upload your diploma or transcript at time of application.
In support of our mission "to improve health every day," this is a tobacco-free environment.
