Medicare Appeal/ Complaint Coordinator - Schenectady
MVP Health Care - Schenectady, NY

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Under the direction of the Appeals Supervisor: Thoroughly investigates and resolves member appeals, complaints, CTM s,and LEP s in professional and timely manner following departmental and company processes and within time limits set forth by CMS guidelines. 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 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 appeal and complaint issues. Maintains working knowledge of Medicare Evidence of Coverage, CMS guidelines, as well as regulatory changes, to ensure correct processing of appeals and complaints. Properly and fully documents member 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, and correspondence 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 rotating weekend and holiday coverage through remote access as needed. Selected individuals will be provided an estimated six eight week training program, to be conducted in Rochester location Performs other duties as assigned. Minimum Education: 2-4-year degree or equivalent amount of education and work experience. Minimum Experience: Experience in Medicare appeals environment Part C and D or 2-3 years Medicare customer service, claims, or related experience. Plus at least 1 year experience in Medicare health insurance environment. Required Skills"Extensive knowledge of Medicare managed care Part C and Part D, 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 (MaxMC or comparable system. Preferred Skills "Experience working with Maximus and ALJ s


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MVP Health Plan covers about 650,000 most valuable people. Also known as MVP Health Care, the company provides health insurance and employee...