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Friday Health Plans Appeals Coordinator in Alamosa, Colorado

Who You Are

You are ready to investigate and resolve complex medical appeals. You are superb at gathering, analyzing and reporting all information for verbal and written claims and authorization grievances and appeals from providers and members. You work collaboratively and very closely with internal departments to resolve and research appeals in a timely manner. You have strong analytical, writing and time management skills.

Who We Are

Friday Health Plans isn?t your average health insurance company. We?re not about unnecessary extras and confusing terminology. We cover the basic health services you?ll likely use the most at a price that just might make your wallet happy. Our simple health plans and friendly service keep you covered so you?re free to live every day like it?s Friday.

As a Denver-based startup company, we?re looking for smart, talented people like you to join us. We value collaboration, innovation, passion, and calculated risk-taking. Now in year four and growing rapidly, we?re looking for people who lead by example, and that example is one of flexibility, reliability, and positivity. If this sounds like you, then we want you on our team.

What You?ll Do:

  • Provide initial review and determine priority of all first and second level, clinical and administrative denials

  • Research clinical records, appropriate insurance regulations and history of claim to determine next step

  • Manage assign queues and categories of appeals to ensure timely determinations

  • Utilize appropriate resources to gather supporting documentation:

  • State EMS protocols

  • Hospital medical records

  • State or Federal Statutes

  • Patient/Physician letters

  • Internal documentation to include claims history and customer service contact

  • Interface with clinical management to assist in medical necessity type denials

  • Assist in gathering all documents, reviewing past submissions and scheduling appropriate parties for External Independent Review requests and ALJ proceedings

  • Ensure proper documentation of all denials into software programs, to include tracking outcome for reporting to appropriate parties. Reporting bodies are:

  • PAC

  • URAC

  • QMPC

  • Department of Insurance

  • Any audits needing documentation and tracking

  • Assist with quality management of all levels of staff appeals, ensuring appropriateness and quality submissions

  • Assist in the resolution of high level payment issues that present financial risk, including but not limited to: self-pay judgments, benefit limitations, timely filing, amount paid on claims and prior-authorization issues

  • Demonstrate the ability to draft professional letters by incorporating supporting documents, policies and statutes

  • Monitor volume of appeals in order to engage additional resources when needed

  • Form professional relationships with payer appeals and utilization departments

  • Solicit hospital records, physician letters, and patient authorization and/or submissions to compile documentation for appeal support

  • Provide communications regarding receipt of new payer requirements, regulations and denial trends

  • Research payer statutes, regulations and regional requirements to support appeal submissions

  • Ensure documentation is saved in appropriate electronic and hard copy locations

  • Ensure open calls, workflows and trend spreadsheets are completed and/or closed

  • Assist in development of policies and procedures to ensure we are compliant with URAC and other regulatory standard timelines

  • Other duties and responsibilities as assigned

Required Knowledge, Skills & Abilities:

  • Attention to detail

  • Highly organized

  • Ability to prioritize and make routine decisions

  • Proficient in Excel

  • Experience using 10-key calculator

  • Willingness to work as part of a team

  • Ability to draft professional and effective letters

  • Experience with Internet-based research

  • Knowledge of patient account systems, revenue management processes, work flow systems, and the ability tot troubleshoot and suggest improvements

  • Demonstrated experience in researching statutes and understanding regulatory documents

Required Education/Experience:

  • Bachelor's degree in business or related field preferred, but not required

  • 1-2 years' experience in medical billing, billing in emergency medical services and collections

  • Experience in Medicare, Managed Care and Workers' Comp processing preferred

  • Experience with medical appeals preferred