Coordinator, Appeals & Complaints

Rochester, NY - Posted: 11/30/17 | SHARE:


Thoroughly investigates and resolves member appeals and CTM’s in a professional and timely manner following departmental and company processes and within time limits set forth by CMS guidelines. Monitors appeals for trends and potential service improvement opportunities. Duties include: Investigates each appeal by gathering pertinent information from members, providers, facilities and internal resources in order to respond to each appeal within the 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 Manager. Suggests service improvement initiatives, if appropriate. Processes and responds to member correspondence, identifying trends and presenting those to Manager. Experience working with IRE’s (currently Maximus) and ALJ’s. 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 identifying trends and presenting those to Manager. Works closely with MVP departments, vendors and external customers to resolve member appeal issues. Maintains working knowledge of Medicare Evidence of Coverage, CMS guidelines, as well as regulatory changes, to ensure correct processing of appeals. Properly and fully documents member appeal 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 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 and correspondence databases. Effectively adapts to changes and understands key business relationships which may affect the Appeals Department. Performs other duties as assigned.



Minimum Education:
2-4- year degree or equivalent amount of education and work experience

Minimum Experience:
Experience in a Medicare Appeals environment Part C and D and at least 1 year of experience in a Medicare health
insurance environment.

Required Skills:
• Medicare Appeals Experience

• 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
• Demonstrated use of Microsoft Office suite products, including Access and Outlook

To Apply: 

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