Appeals Reviewer

Responsibilities

• Optimize work processes to independently conduct comprehensive research to gather information regarding member appeals and provider inquiries by analyzing, evaluating and investigating all issues involved, then collaborating with applicable departments to ensure timely handling of appeals in accordance with the current Fund’s policies, guidelines, and regulatory requirements.

• Provide written acknowledgments to appellants and/or authorized representatives upon receipt of appeals.

• Responsible for outreaching to member, provider and/or authorized representative (e.g., vendor, attorney, etc.) verbally and/or in writing during the research and/or appeal process to answer questions, provide guidance, and clarify information/outstanding concerns regarding the appeal request.

• Ensure accountability by monitoring appeals daily to ensure all requests are kept within compliance, including, but not limited to: Preparation of appeals for medical and administrative review by summarizing findings of the investigation, maintaining accurate, timely, and complete record of appeals in the Appeals Tracking System (ATS); following-up and escalating when compliance standards are at risk to assure timely disposition & swift resolution.

• Ensure appeal documentation supports the outcome of the appeal; requirements are met by electronically archiving all correspondence with members/dependents or authorized representatives (e.g., providers, vendors, etc.)

• Access multiple systems to determine benefit entitlements, claims processing guidelines, and plan rules related to the appeals for all 1199SEIU Family of Funds; e.g. QNXT portals, Member (Eligibility, Memos/Alerts, UM Documents, etc.); Claims to gather information regarding prior activity related to denied services being appealed;, Provider to determine contractual agreements and pay to affiliations;, V3 (Vi-Tech) to verify eligibility guidelines (e.g. COB, COBRA, etc.), & third party vendors, (e.g., eviCore, Care Continuum, etc.) to determine level of appeal, prior authorization status, etc.

• Collaboratively communicate final appeal decisions thoroughly and accurately with appellants and/or authorized representatives via written correspondence

• Assist Supervisor in auditing work of Chief Clerk II and redistribute errors; Provide departmental side by side mentoring of staff

• Inbound and Outbound communication with members, authorized representatives, providers, etc. verbally and in writing, via Appeals Hotline and/or email, maintaining HIPAA compliance, with members, providers, authorized representatives, other healthcare professionals regarding appeals processes, Fund benefits, policies and procedures, plan changes for all 1199SEIU benefits and programs (including but not limited to NBF, GBF, HCF benefit and Pension, CCF, TEF, etc.); explain the appeal process including helping members understand the outcome and implication of appeal decisions

• Communicate updates and status of outstanding appeals/issues to management, to include, identifying trends and report results; keep current with rules, regulations, policies and procedures relating to plan member benefits, member rights and responsibilities and complaints and grievances

• Maintain various logs, i.e. daily phone logs, weekly/monthly productivity reports and other statistical reports, as necessary

• Index and Archive documents/files electronically in DMS

• Perform other duties and assignments as directed by management

Qualifications

• High School Diploma or GED required; some college or degree preferred

• Minimum two (2) years’ experience examining and resolving health claims in a health insurance or benefits environment or two (2) year experience examining claims with comprehensive knowledge of NBF, GNY and HCF eligibility, rules for extended or limited continuation of benefits and benefit administration required; and one (1) year customer service experience in person or via phone required

• Comprehensive knowledge of health claim systems, Current Procedural Terminology (CPT) codes and Internal Classification of Diseases (ICD-9 and ICD-10) codes required

• Knowledge of 1199SEIU Fund eligibility rules and benefits required (National Benefit Fund, Greater New York and Home Care Fund)

• Experience navigating web-based applications and Call Tracking Systems (ViTech, Qnxt, etc)

• Ability to work well under pressure, multi-task, establish priorities, meet deadlines and follow-up

• Good problem solver and excellent analytical skills

• Excellent communication skills (written and verbal) and interpersonal skills’ ability to maintain a pleasant attitude with member, providers and/or their authorized representatives (i.e.. vendors, attorneys) to ensure customer satisfaction.

• Must meet attendance and punctuality standard