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Appeals Coordinator

Send to my Email Email a friend Job ID 77283 Date posted 11/15/2016
Requisition ID: 77283
  • Facility: Sharp HealthPlan
  • City: San Diego
  • Department: Operations
  • Category: Business Operations Jobs
  • Job Status: Full-Time
  • Shift: Day Job
  • FTE: 1.0
  • Shift Start: 8:30 AM
  • Shift End Time: 5:30 PM
Location
This position is located in Kearny Mesa, San Diego County
 
Hours

8:30am-5:30pm

 
Required Skills and Qualifications
  • Three years' experience in claims, utilization review, appeals or member services in a managed care environment
  • Thorough understanding of managed care principles and models
  • Thorough understanding of health services and delivery models, including hospital, physician, ancillary, home health, prescription drugs, etc.
  • Knowledge of various managed care reimbursement methodologies
  • Ability to analyze and interpret data, and prepare summary reports from findings
  • Familiarity with DMHC, DHS, CMS and other regulatory agency standards related to appeals and grievances
  • High level of integrity, ethical practices, innovative thinking, ability to exercise sound judgment and maintain confidentiality
  • Able to exercise mature and sound judgment in the commitment of the Plan's mission and operating goals
  • Exceptional diplomacy skills to effectively resolve issues under sometimes tense and stressful circumstances
  • Able to follow strict timelines and manage multiple tasks concurrently
  • Flexible. Able to work independently and as a member of a cohesive, results-oriented team.
  • Excellent organizational and interpersonal skills
  • Computer skills must include experience with electronic mail, word processing, spreadsheets, database programs and the IDX Managed Care application
  • Adept in both written and oral communications
  • Strong writing skills
Preferred Skills and Qualifications
  • Bachelors in Business Administration or Health Care Administration, including courses of study in accounting, finance, marketing, and health care administration
  • Familiarity with Internet
  • Experience with Medicare
  • Bilingual (English/Spanish)

Summary
The Appeals Coordinator is responsible for the investigation, documentation and resolution of member appeals and grievances in compliance with State law, rules, and guidelines; provider and group agreements; Operations Manual; benefit matrices; and other administrative and medical guidelines, policies, and procedures. Works closely with the Chief Medical Officer (CMO) who is responsible for all decisions regarding clinical appeals and grievances and the Chief Operations Officer (COO) who is responsible for non-clinical appeals and grievances.
The Customer Care Department provides superior customer service to Sharp Health Plan members, provider, employers, brokers and others.
Sharp Health Plan is San Diego’s only locally based commercial health plan. With a personal approach and a superior network of medical groups and physicians, Sharp Health Plan advocates for its members by providing unparalleled quality and access to health care services. It operates as a not-for-profit health plan, committed to delivering the best health care for the best value.
Sharp Health Plan is the largest locally based commercial health plan in San Diego. We are a not-for-profit health plan that has been serving San Diego and southern Riverside Counties since 1992. As a subsidiary of Sharp HealthCare, we are backed by the largest provider of comprehensive health care services in San Diego.  
Sharp Health Plan offers a variety of coverage options that combine affordability and choice, while delivering high quality health care and personal service. We provide health insurance for companies of all sizes throughout the region. Members have access to valuable plan enhancements, such as interactive wellness resources, dental discounts and our exclusive global emergency services program.
As one of the top-rated health plans in California (as measured by the CAHPS satisfaction survey), Sharp Health Plan serves a growing number of companies, large and small, in San Diego and southern Riverside counties.
Essential Physical Requirements may include
  • Sitting
  • Gripping/Grasping
  • Fine Manipulation / Pinching
  • Reaching below shoulder level
  • Keyboarding
  • Mousing
  • Lifting up to 10 pounds
  • Push/Pull up to 50 pounds
  • Carrying up to 10 pounds
Additional physical requirements of position may be discussed during interview.

Sharp HealthCare is proud to be an Equal Opportunity/Affirmative Action Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, gender identity, transgender status, sexual orientation, protected veteran status or any other protected class.

Keywords: Appeals Coordinator, Investigation, documentation, resolution, member appeals,grievances , compliance, State law, rules, provider agreements, group agreements, utilization review, IDX Managed Care application
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