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Job Summary

The Appeals Coordinator is accountable for reviewing appeals pursuant to an adverse benefit determination within the timeframes set forth in both federal and state law by applying corporate and medical guidelines and policies. This position requires extensive knowledge of Federal, State, payer regulations, and reimbursement methodologies to facilitate timely and accurate reimbursement. This position must favor neither the Company nor the member and must exercise independent judgment in determining whether or not an adverse benefit determination was legal, appropriate, impartial and fair. This position reports to Senior Counsel.

Requirements

EDUCATION

Bachelor's degree in Nursing preferred.

LICENSING/CERTIFICATION

Registered Nurse (RN) with current active state license in good standing in the state(s) where job duties are performed required.

EXPERIENCE

Minimum five (5) years' clinical nursing experience, to include a broad background in various facets of nursing.

Knowledge of HCPCS/CPT/Revenue codes and general coding principles.
Knowledge of claims processing rules/logic.
Knowledge of Health Plan operations, regulatory agencies and State/Federal regulations related to health care.

Minimum two (2) years' in utilization review, medical policy, and/or case management experience required. Previous experience in appeals and/or grievances process preferred.

ESSENTIAL SKILLS & ABILITIES

Excellent oral & written communication skills
Detail-Oriented

Strong analytical, critical thinking, organizational and time management skills

Proficiency using basic computer skills in Microsoft Office such as Word, Excel, Outlook, and PowerPoint, including the ability to navigate multiple systems and keyboarding.

Ability to make sound judgments and decisions based on facts and guidelines.
Ability to build collaborative relationships.
Ability to work independently with little supervision.
Ability to interpret complex documentation.

Skills

• Analytical Decision Making • Business Compliance • Collaborative Communications • Critical Thinking • Cross-Functional Communications • Data Analysis • Document Recording • Information Interpretation • Interpersonal Relationship Management • Law • Microsoft Excel • Microsoft Office • Needs Assessment • Researching • Sound Judgment • Time Management

Responsibilities

• Appeals: Researches appeal cases for diagnosis codes and medical necessity; provides comprehensive responses, according to accepted standards of medical practice and corporate medical policy, code review logic, contractual guidelines and regulatory requirements. • Communication: Collaborates with various medical divisions concerning legal issues related to benefits and must be able to understand and explain medical coverage policy application. Respond to the Arkansas Insurance Department and any other state insurance department who has received a complaint and to any appeal of an adverse benefit determination made by a member, provider, attorney or personal representative of a member of Arkansas Blue Cross within the timeframe allowed by state and federal law. • Compliance: Practices nursing within the scope of licensure and adheres to policies, procedures, regulations, URAC standards and individual state regulations; making decisions based on facts and evidence to ensure compliance, appropriate level of care, and patient safety. • Knowledge: Remain current with up-to-date medical and surgical procedures, products, healthcare services and drugs, general trends in health care delivery; and enterprise procedures, policies and contracts. • Other duties as assigned.

Certifications

Registered Nurse (RN) - Arkansas State Board of Nursing

Security Requirements

This position is identified as level three (3). This position must ensure the security and confidentiality of records and information to prevent substantial harm, embarrassment, inconvenience, or unfairness to any individual on whom information is maintained. The integrity of information must be maintained as outlined in the company Administrative Manual.

Segregation of Duties

Segregation of duties will be used to ensure that errors or irregularities are prevented or detected on a timely basis by employees in the normal course of business. This position must adhere to the segregation of duties guidelines in the Administrative Manual.

Employment Type

Regular

ADA Requirements

2.1 General Office Worker, Semi-Active, Campus Travel - Someone who normally works in an office setting or remotely, periodically has lifting and carrying requirements up to 40 lbs and routinely travels for work within walking distance of location of primary work assignment as essential functions of the job.