Thoroughly investigates and resolves appeals and complaints in professional and timely manner following departmental and company processes and within time limits set forth by member or provider contracts. Monitors appeals and complaints for trends and potential service improvement opportunities. Duties include: Investigates each appeal or complaint by gathering pertinent information from members, providers, facilities and internal resources in order to respond to each appeal or complaint within designated time requirements. Sends timely resolution letters for cases. Serves as primary case contact for member, provider, and medical director reviewer questions or requests. Monitors cases for trends, and reports trends to Supervisor. Suggests corrective action or service improvement initiatives, if appropriate. Processes and responds to member/ provider correspondence, identifying trends and presenting those to Supervisor. Educates members and providers on MVP policies, procedures and member benefits. Provides appeal process training to MVP staff. Performs claims and coding research to facilitate processing of appeals or complaints, identifying trends and presenting those to Supervisor. Works closely with MVP departments, Vendors and external customers to resolve member/provider appeal and complaint issues. Maintains working knowledge of MVP Certificate of Coverage, Member Handbooks, Medicare Evidence of Coverage and Summary Plan Descriptions, as well as regulatory changes, to ensure correct processing of appeals and complaints. Properly and fully documents member/provider appeal or complaint, including full documentation of contacts made or received, as well as any correspondence sent/received. Sends clearly written detailed correspondence to members and providers for each appeal, complaint, or correspondence, in a timely manner. Communicates clearly and effectively in either written correspondence or orally, and demonstrates appropriate level of tact and diplomacy with internal/external contacts. Exhibits high level of conflict resolution skills. Maintains and updates appeal, complaint, correspondence and provider databases. Acts as liaison between MVP s Medical Directors and providers in assisting with physician-to-physician telephone calls when requested. Effectively adapts to changes and understands key business relationships which may affect the Appeals Department. Performs other duties as assigned.
Minimum Education: 2-4-year degree or equivalent amount of education and work experience
Minimum Experience: 2-3 years of previous customer service, claims, or other related experience, plus at least 1 year of experience in health insurance or an appeals environment
" Extensive knowledge of managed care, including health care benefits, regulations, medical and administrative policies, and claims payment processes
" Demonstrated strong verbal and written communication, organizational, analytical, and interpersonal skills
" Strong commitment to customer service and understanding and responding to customer needs
" Strong problem solving skills and ability to thoroughly follow issues through to resolution
" Ability to maintain a high level of discretion in dealing with confidential member medical and company-sensitive information
" Demonstrated use of Microsoft Office suite products, including Access and Outlook
" Demonstrated knowledge of medical management documentation/tracking systems such as maxMC or comparable system
" Medicare and/or Part D knowledge
MVP Health Plan covers about 650,000 most valuable people. Also known as MVP Health Care, the company provides health insurance and employee...