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Appeals Associate

4 months ago

Bronx, United States BronxCare Health System Full time

Appeals associate will be responsible for coordinating and monitoring the administrative and non-clinical services for the clinical appeals team. These duties include, but are not limited to, setting up work assignment schedules, investigating, analyzing, providing statistical reports and reporting patterns as applicable to the clinical appeals department. He/ She provide these services in an efficient manner ensuring that denial process is up to date.Prepare reports for the director on a weekly and monthly basis from the denial database in order to identify service and physician. Assist in the implementation of procedures to decrease untimely appeals and promote timely submission pertaining to inpatient admission denials 


Establish and maintain positive relationships with patients, visitors, and other employees. Interacts professionally, courteously, and appropriately with patients, visitors and other employees. Behaves in a manner consistent with maintaining and furthering a positive public perception of BronxCare Health System and its employees.Maintains continuous dialogue with all Payors regarding the Clinical appeals management process. Assists the IPRO agents on onsite review process. Identify problems that impact on clinical appeals unit- participate in performance improvement activities and provide statistical reports as required .Print Medical records- Admission notes, Progress notes, Nurse progress notes, Medical order, Lab results (15 to 20 cases per day) pertaining to Appeals and mail them out to the corresponding Payor along with Appeal and the Cover Letter.Update the appeal status report on a daily basis. Monitors and follows-up with the clinical information being presented to Managed Care Organizations. Follow up on the Appeal determination (Appealed cases without determination after 60 days) - Call the Insurance Payors (5 cases)- ask for determination and update care manager and appeal status report.Sort cases based on time frame and notify to clinical team on a weekly basis. Receive Payor communications from the clinical team- via Email and update the care manager and appeal status report Retrieves Payor communication from the lock box. Sends Initial adverse determinations to PFS team for denial creation, Print attaches and updates the care manger with the appeal determinations.Assists the Director with the scheduling and conducting of monthly meetings with the staff of clinical appeals. Confers with the Director and/or designee in the evaluation of review activity. Makesrecommendations regarding improvement of same. Operates standard office equipment ,Performs other duties as assigned. Assumes special projects as deemed appropriate by the Director and/or designee of clinical appeals department.


Experience in health care environment preferred
Experience in Electronic medical records and processing environment preferred
Experience in Excel spread sheets, Microsoft word required
Strong communication skills both verbal and written required
Ability to multitask and willingness to learn new skills