Job Responsibilities : Hiring: Remote Provider Appeals Coordinator (Work from Home Jobs)
Salary : Competitive Salary
Company : WellSense Health Plan
WellSense Health Plan is a nonprofit health insurance company serving members across Massachusetts and New Hampshire through Medicare, Individual and Family, and Medicaid plans. Founded 25 years ago as Boston Medical Center HealthNet Plan, we provide plans and services that work for our members, no matter their circumstances.
It’s an exciting time to join the WellSense Health Plan, a growing regional health insurance company with a 25-year history of providing health insurance that works for our members, no matter their circumstances.
The Provider Appeals Coordinator is responsible for managing the overall coordination investigation, documentation and the resolution process of medical claims appeals from providers. This includes analysis, preparation, evaluation of prior determinations, coordination of clinical review, claims review, etc., investigation, documentation and the resolution process of medical claims appeals from providers while ensuring compliance with policies and procedures under WellSense (BMCHP), MassHealth, Commonwealth Care contracts and NCQA standard guidelines.
Our Investment in You:
Full-time remote work
The Provider Appeals Coordinator is responsible for all activities associated with appeal analysis, decision-making and closure as follows:
Responsible for the preparation and research of data and records required to assure timely processing of administrative appeals in compliance with WellSense (BMCHP)
Review claim coding and claim processing history, medical policy and reimbursement policies, regulatory and legal requirements, and provider contracts.
Maintain files on individual appeals and coordinate management of provider appeals with other departments through resolution.
Collaborate effectively with coding specialists, appeal nurses, and others as necessary to reach timely decisions on appeals.
Make non-clinical appeal determinations as permitted by department business processes and guidelines. Follow department’s processes to receive a clinical review and decision from licensed health professionals. Documents, investigates and facilitates the resolution of provider administrative appeals, including the writing, review, and approval of resolution letters.
Track provider appeals in appropriate systems and assist in the maintenance of files.
Assist with compilation of reports on appeals, including trends, number of cases, decisions, suggestions for process improvement, types of appeals and compliance with timelines.
Maintains the Provider Appeals process and workflow toward; provider satisfaction and claims payment accuracy under MassHealth, Commonwealth Care contract requirements and NCQA accreditation guidelines where applicable.
Establish and ensures workflow continuity with the Plan in the areas of Claims Processing; Provider Servicing and Health Services.
Manage a defined caseload within department productivity and quality expectations and provide back up for other appeals staff.
Adhere to dependability, customer focus, and all performance criteria as established by the department including: timeliness, production, and quality standards for all work
Other duties as assigned
Bachelor’s degree in Health Care Administration, related field or, an equivalent combination of education, training and experience is required.
Experience with claims processing and appeals
Strong verbal, written, customer service and problem-solving skills.
2+ years grievance or appeals, claims or related managed care experience
Competencies, Skills, and Attributes:
Demonstrated initiative and analytical ability in identifying problems, researching issues, developing solutions, and implementing a course of action.
Knowledge of medical terminology, anatomy and coding (CPT, DX, HCPCs).
Detail oriented, excellent proof reading and editing skills
Ability to listen and communicate appropriately in a manner that promotes positive, professional interaction while maintaining confidentiality and sensitivity in all aspects of internal and external contacts.
Strong working knowledge of Microsoft Office products (e.g. Microsoft Word, Excel, Outlook).
Ability to work in both team and independent settings
WellSense Health Plan is a nonprofit health insurance company serving more than 440,000 members across Massachusetts and New Hampshire through Medicare, Individual and Family, and Medicaid plans. Founded 25 years ago, WellSense provides high-quality health plans and services that work for our members, no matter their circumstances.
*WellSense will require proof of COVID-19 vaccination(s) as a term of employment for all employees. The company may make exceptions to this requirement in certain limited circumstances for religious or medical purposes.