Appeals Coordinator Resume Sample

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Hosea Jerde
602 Howe Tunnel,  Philadelphia,  PA
+1 (555) 810 3786

Work Experience


Senior Appeals Coordinator
03/2018 - PRESENT
Chicago, IL
  • Serves as a liaison in corresponding and communicating with providers and members or members’ representatives as needed during appeal processing
  • Works closely with the organization’s third-party physician advisor in requesting clinical justification letters for retrospective, medical necessity and coding appeals
  • Performs administrative activities including, but not limited to, generating, printing and mailing determination and authorization notification letters. Completes all associated data entry and authorization creations in WellCare systems. Correctly and completely preps completed case files for scanning and archiving
  • Serves as a liaison in corresponding and communicating with providers and members or members’ representatives as needed during AC&G processing
  • Responsible for interface with members and providers as required regarding status, process and outcomes of complaints and appeals
  • Coordinates the appeal and dispute process through the collection of clinical records and consultation with Physician Advisors/Medical Director and communicates final determination
  • Maintain a caseload of appeals, non-authorizations, provider disputes and/or PA review scheduling as assigned- Process appeals, non-authorizations and provider disputes according to policies, work flows
  • Document process and findings within database
Appeals Coordinator
01/2014 - 10/2017
Los Angeles, CA
  • Contact and respond to members and providers within required timeframes as required by contracts, regulations and standards
  • Prepare written materials following policies and procedures for notification and tracking purposes of appeals, provider disputes and PA review scheduling
  • Identify risk areas and reports such to unit manager
  • Consult with manager on problem cases and interfaces with unit staff in data obtainment and resolution
  • Prepare and present information on non-authorizations, appeals and provider disputes to external review organizations and customers
  • Assist in data gathering and reporting of non-authorizations, appeals and provider disputes
  • Contribute to CMC/Magellan office and department CQI processes by participating in unit goal setting, scorecard development and departmental meetings
  • Serves as a liaison in corresponding and communicating with providers and members or members' representatives as needed during appeal processing
Claims Audit & Appeals Coordinator
10/2011 - 12/2013
San Francisco, CA
  • Provides guidance and training to less experienced staff on policy, procedure and best practice
  • Handles more complex/elevated cases and assists management with projects and audits
  • Performs administrative activities including, but not limited to, generating, printing and mailing determination and authorization notification letters. Complete all associated data entry and authorization creation in WellCare systems. Correctly and completely prep completed case files for scanning and archiving
  • Develops and presents ideas for performance and process management improvement within the department. Notify Supervisor or other appropriate parties of identified patterns of appeals, claim errors, configuration issues, or other systemic problems identified during appeal processing
  • Assists in data gathering and reporting of appeals. Responsible for assisting in achieving and maintaining department performance guarantees
  • Assists in UM related workflows and innovative process improvements to positively impact the department overall
  • Contributes to unit and department CQI (continuous quality improvement) processes by participating in unit goal setting, scorecard development and departmental meetings
  • Meets individual performance standards

Education


Kent State University - Trumbull Campus
2006 - 2010
School's Degree in Management

Professional Skills


  • Outstanding verbal communication skills, and proven track record in effective customer services relations required
  • Demonstrates good judgment and problem-solving skills
  • Time management skills with an ability to establish priorities and accomplish tasks in a timely and accurate manner
  • Strong computer skills (Microsoft Excel, Word, Office)
  • Strong organizational, analytical, investigative, and problem solving skill
  • Advanced Excel skills required (Pivot Tables, V-look ups, formula writing)
  • Accurate alphabetic, numeric, and/or terminal-digit filing skills

How to write Appeals Coordinator Resume

Appeals Coordinator role is responsible for database, computer, supervision, word, research, training, reporting, design, insurance, government.
To write great resume for appeals coordinator job, your resume must include:

  • Your contact information
  • Work experience
  • Education
  • Skill listing

Contact Information For Appeals Coordinator Resume

The section contact information is important in your appeals coordinator resume. The recruiter has to be able to contact you ASAP if they like to offer you the job. This is why you need to provide your:

  • First and last name
  • Email
  • Telephone number

Work Experience in Your Appeals Coordinator Resume

The section work experience is an essential part of your appeals coordinator resume. It’s the one thing the recruiter really cares about and pays the most attention to.
This section, however, is not just a list of your previous appeals coordinator responsibilities. It's meant to present you as a wholesome candidate by showcasing your relevant accomplishments and should be tailored specifically to the particular appeals coordinator position you're applying to. The work experience section should be the detailed summary of your latest 3 or 4 positions.

Representative Appeals Coordinator resume experience can include:

  • At least 12 months experience in Senior Business Unit (SBU), Enrollment, Maintenance and Billing (EM&B) or Medicare experience
  • Reviews NOMNC for validity prior to processing appeal request
  • Professional verbal and written communication skills, with the ability to clearly articulate thoughts and resolutions concisely
  • Organizational skills with the ability to handle multiple tasks and/or projects concurrently with minimal supervision
  • Proficient computer skills for Windows Microsoft Office Applications (Word and Power Point)
  • Apply applicable contract language, benefits and covered services from the Evidence of Coverage (EOC) in researching and deciding the outcome of appeals

Education on an Appeals Coordinator Resume

Make sure to make education a priority on your appeals coordinator resume. If you’ve been working for a few years and have a few solid positions to show, put your education after your appeals coordinator experience. For example, if you have a Ph.D in Neuroscience and a Master's in the same sphere, just list your Ph.D. Besides the doctorate, Master’s degrees go next, followed by Bachelor’s and finally, Associate’s degree.

Additional details to include:

  • School you graduated from
  • Major/ minor
  • Year of graduation
  • Location of school

These are the four additional pieces of information you should mention when listing your education on your resume.

Professional Skills in Appeals Coordinator Resume

When listing skills on your appeals coordinator resume, remember always to be honest about your level of ability. Include the Skills section after experience.

Present the most important skills in your resume, there's a list of typical appeals coordinator skills:

  • Computer skills: MS Office (Word, Outlook, Excel) and the ability to work with web-based applications
  • Experience in appeals/claims/scheduling or coordinating
  • Previous experience with Health Insurance and Denials
  • Extensive knowledge and experience in claims, benefits, and member contracts
  • Review contracts, Evidence of Coverage, medical payment policies, and Provider education documents in researching and deciding the outcome of appeals
  • Two years' experience in claims, utilization review, appeals or member services in a managed care environment

List of Typical Experience For an Appeals Coordinator Resume

1

Experience For Grievance & Appeals Coordinator Resume

  • At least 12 months of Claims experience to include researching for payments, denials and adjustments
  • Experience using Siebel, Diamond and other Medicare databases
  • Sends review to MD for rescinding NOMNC when necessary, following nH processes
  • Accountable for knowing and keeping standards in compliance
  • Assist in maintaining timeliness requirements for the review of post-determination requests
2

Experience For Claims Audit & Appeals Coordinator Resume

  • Maintain daily and monthly tracking logs
  • Prepares monthly and quarterly reports reflecting accurate denial data in a timely fashion
  • Provides support for ongoing projects as required
  • Maintain a caseload of appeals, non-authorizations, provider disputes and/or PA review scheduling as assigned
  • Process appeals, non-authorizations and provider disputes according to policies, work flows
  • Facilitates and coordinates with internal and external customers in a proactive manner to bring requests to a satisfactory resolution in a timely fashion
  • Process requests of individual clients’ TAT standards and special case handling requirements
  • Open to any level of Appeals Coordinator (l,ll,lll)
3

Experience For Grievances / Appeals Coordinator Resume

  • Consult with manager on problem cases and interfaces with unit staff in data obtainment and resolution of complaints and appeals
  • Prepare and present information on appeals and complaints to external review organizations and customers
  • Analyzes and renders final decisions of appeals and grievances according to procedure, state and federal guidelines, benefit plan guidelines, company internal policies and work flows
  • Coordinates the appeal and grievance process through the collection of information or records and consultation with Physician Advisors/Medical Director as needed and communicates final determination
  • Responsible for interface with members and providers as required regarding status, process and outcomes of appeals and complaints
  • Owns assigned appeal requests or determination notifications that are received via fax, phone, or email
4

Experience For Senior Appeals Coordinator Resume

  • Processes appeal or notification in accordance to CMS and nH guidelines and compliance policies
  • Creates DENC letter as part of appeal process, by reviewing and documenting member clinical information and sends letter to member, QIO entity, and/or Health Plan representative
  • Coordinates and communicates with care coordinators, physicians, health plan representatives, QIO entity, and providers regarding the appeal or determination and provides education as needed
  • Participates in after-hours on-call rotation and weekend rotation for processing pre-service authorizations and appeals
  • Processes Health Plan appeal notifications and determinations as needed
  • Follows processes for documentation of the appeal in the nH Coordinate
  • Completes all associated data entry and authorization creations in WellCare systems
  • Notifies Supervisor or other appropriate parties of identified patterns of appeals, claim errors, configuration issues, or other systemic problems identified during appeal processing
5

Experience For Medicare Advantage Grievance & Appeals Coordinator Resume

  • Excellent organizational and office administrative skills required
  • Behavioral Health, Healthcare or Managed Care Industry experience
  • Experience with automated databases and standard PC business software applications required
  • Excellent written communications required
  • Medicaid/Medicare Grievance Appeals Experience; Required
6

Experience For Utilization Appeals Coordinator Resume

  • Maintain confidentiality of all protected health information in accordance with state and federal guidelines and corporate policies and procedures
  • Interface with the appropriate ValueOptions management and staff at all levels to present and summarize Complaint and Appeal cases
  • Ensure members’ appeal right are upheld and the corporate is in compliance with government guidelines
  • Identifies and investigates the reason for denial trends and report findings to the appropriate entities
  • Update and generate authorizations for services that have been appealed, as well as communicate this information to various departments
  • Documents, in the appropriate computer system, all correspondence with a member and or a provider related to an appeal or grievance issue
7

Experience For Temporary Grievances / Appeals Coordinator Resume

  • Tracks and reports case turn around time and follows up with the plan, when this requirement is not met
  • Keeps current with rules, regulations, policies and procedures relating to Plan member benefits, member’s rights and responsibilities, and Complaints and Grievances
  • Maintains the performance standard of processing 95% of all member first level appeals within 30 days and grievance within 90 days of receipt, as defined in all regulatory and accreditation standards
  • Follows up when compliance standards are not meet
  • Adheres to Plan policies and procedures and supports the mission and values of Plan.
  • Assemble and forward clinical and administrative case documentation to clients
  • Attach faxed medical records to the appropriate Informa authorization record
  • Communicate directly with health plan designees, providers, members, and internal clinical and non-clinical staff
  • Maintain administrative responsibilities for the appeals unit
8

Experience For Audit & Appeals Coordinator Resume

  • Receive case documentation from health plan representatives and initiate the appropriate review process
  • Recreate authorizations in the Informa system
  • Restatus authorizations in Informa as directed by the appeals unit ICRs
  • Review clinical documentation to determine completeness of information for review
  • Experience in a healthcare setting (hospital, physician office, health plan) required. At least six months experience as an authorization representative in a utilization management call center
9

Experience For Ssc-denials & Appeals Coordinator Resume

  • Track and monitor the movement of assigned cases through A&G application and organization systems
  • Review research performed by operational areas (Call Center, Claims, Medical Management, Provider Relations, etc.) to assure the appropriate resolution to the appeal has been achieved
  • Document that timely and accurate actions are taken both electronically and in hard copy
  • Monitor and document the effectuation of all overturned determinations as a result of Plan or independent review entity (IRE) determination
  • Adhere to all quality, compliance, and regulatory guidelines established by CMS and set forth by other regulatory agencies, where applicable, and defined in the UAM corporate and department policies
  • Foster an environment for open communication and collaborative practice
  • Work weekend and holiday "on-call" as assigned to provide coverage for expedited related complaints
10

Experience For Expedited Appeals Coordinator Resume

  • Produce work that is highly accurate and reflects well on the organization
  • Decision-making skills with the ability to investigate and weigh alternatives and select the course of action that provides the greatest benefit to the member and organization
  • Interpersonal telephone skills with the ability to work in a fast-paced environment and participate as an independent contributor with little supervision or as an active team member depending on the situation and needs
  • Updates and maintains all data bases to maintain data integrity
  • Identifies trends in payer behavior and site denial activity

List of Typical Skills For an Appeals Coordinator Resume

1

Skills For Grievance & Appeals Coordinator Resume

  • Three years' experience in appeals/grievances, claims, utilization review, or member services in a managed care environment
  • Able to demonstrate proficiency in various client managed care software platforms
  • Three years' experience in claims, utilization review, appeals or member services in a managed care environment
  • Close vision required to see computer monitor, read documents, and operate copy and fax machine
  • Experience researching and resolving appeals
  • Professionalism and experience in handling confidential materials and sensitive matters
  • Demonstrated expertise in Microsoft Office Products including Word, Excel, and Access
  • Three years Patient Access/Financial Investigation experience
  • Demonstrates an ability to facilitate both medical and behavioral health reviews in coordination with physicians
2

Skills For Claims Audit & Appeals Coordinator Resume

  • Demonstrates ability to handle majority of processes in department
  • Working knowledge of Star hospital system registration functions
  • Maintains case management and tracking systems for appeals pending before ONRR, IBLA, IBIA, and federal courts
  • Prepare written materials following policies and procedures for notification and tracking purposes of complaints and appeals
  • Assist in data gathering and reporting of non-clinical appeals and complaints
  • Correctly and completely preps completed case files for scanning and archiving
  • Responsible for timely and accurate written documentation to the member and/or provider advising of the resolution of the appeal
  • Distance vision required to drive an automobile, if driving is a requirement of the job
3

Skills For Grievances / Appeals Coordinator Resume

  • Review documentation and appeals including
  • Maintains accurate daily logging of all reviews
  • Maintains expertise regarding appeals procedures, statutes, regulations, lease terms, and guidance documents
  • Assist in maintaining timeliness requirements for the review of determination requests
  • Maintain a caseload of non-clinical appeals and/or complaints as assigned- Process non-clinical appeals/complaints according to policies, work flows
4

Skills For Senior Appeals Coordinator Resume

  • Prepares, develops and presents written case summaries for all adverse determination for the purpose of conducting State Fair Hearings
  • Actively seeks the involvement of the legal department or government affairs, whenever necessary, for clarification and supporting documentation
  • Responsible for communicating NCQA requirements to appropriate personnel involved in the member appeal process
  • Knowledge of and/or ability to learn and use personal computers and industry software such as Peradigm, Sidewinder, and EMMA LI-RG1
  • Researches and responds to requests related to billing and/or admission status. Investigates cases rejected for payment, secures requested information and prepares for rebilling
  • Organizes and coordinates cases of assigned workload for admission and concurrent authorizations. Includes documentation in both electronic billing system and electronic Care Management system
  • Works collaboratively with Care Coordinators and through chart review to request and obtain appropriate clinical information required for admission and concurrent reviews. Reviews cases for medical necessity using InterQual when appropriate. Obtains admissions status order to correlate with status as followed by licensure
  • This is a temporary role
  • Review all incoming verbal and written complaints received throughout the day. Enter all appeals in the Appeals database and expeditiously transfer misrouted complaints and correspondence to the appropriate area for processing
5

Skills For Medicare Advantage Grievance & Appeals Coordinator Resume

  • Conduct thorough investigations of all member and provider appeals by analyzing all the issues involved and obtaining responses and information from internal and external entities
  • Review research performed by operational areas to assure the appropriate resolution to the appeal has been achieved
  • Serve as a liaison with internal departments, delegated entities, and network providers to ensure timely resolution of appeals
  • Ensure appeals are processed within applicable timeframes
  • Responsible for the timely and accurate documentation of the appeal
  • Enter and maintain critical data and records in support of ConnectiCare’s (“CCI) business requirements, regulatory timeframes, and NCQA standards, in the appropriate systems
  • Track and trend outcomes, analyze data, and provide reports required to Director, Appeals and Compliance, appropriate committees, and internal departments. Identify areas for quality improvement and recommend revisions to network contracting and policies and procedures as necessary
  • 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
6

Skills For Utilization Appeals Coordinator Resume

  • Actively participate on assigned committees and projects
  • Familiarity with DMHC, DHS, CMS and other regulatory agency standards related to appeals and grievances
  • Flexible. Able to work independently and as a member of a cohesive, results-oriented team
  • Adept in both written and oral communications
  • Bachelors in Business Administration or Health Care Administration, including courses of study in accounting, finance, marketing, and health care administration
  • Familiarity with DMHC, CMS and other regulatory agency standards related to appeals and grievances
  • Familiarity with Internet research
7

Skills For Temporary Grievances / Appeals Coordinator Resume

  • Able to quickly grasp and implement newly acquired knowledge of any company managed care software platforms
  • Able to type 50 words per minute with at least 95% accuracy
  • Sit, use hands and fingers, talk or hear, and smell continually
  • Stand, walk and reach frequently
  • Climb or balance, stoop, kneel, or crouch occasionally
8

Skills For Audit & Appeals Coordinator Resume

  • Licensed as an RN or LPN in the State of Michigan for nurses in the role
  • Accredited Record Technologist or Registered Records Administrator with state-required credentials
  • Review case notes and contact employee to verify and obtain additional information
  • Make additional contacts to obtain information (doctor, manager, etc.)
  • In a managed health care environment with a solid understanding of member and provider rights and responsibilities, particularly with appeals and grievances is required. Familiarity with managed care state and federal regulations required
  • Tracking and trending issues that are being appealed
  • Knowledge of CMS Part C appeal processing requirements, Medicare Coverage resources (MMCM, BPM, and CPM, LCD, NCD, etc.) as well as the IRE, MAXIMUS Federal Services' Reconsideration Manual
  • Working knowledge of health plan operations with emphasis on Claims, Medical Management, Call Center and Provider Relations
  • Position requires basic knowledge of medical and behavioral health terminology
9

Skills For Ssc-denials & Appeals Coordinator Resume

  • Knowledge of Utilization Review Accreditation Commission (URAC), National Committee of Quality Assurance (NCQA), HIPAA compliance standards and the implications inherent in the handling of PHI information
  • Practical work experience: preferably exposure to a managed care environment, physician’s office, hospital business office, or a medical/behavioral health services environment
  • Investigate appeals by gathering supporting documentation from internal departments, contract and non-contract providers and entities, as indicated
  • Screen all incoming grievances, appeals and provider claim dispute to ensure they are in compliance with CMS guidelines and the corporation’s policies
  • Make verbal contact with the member/ authorized representative during the appeal research and development process
  • Send timely and accurate written correspondence to the member, authorized representative or provider advising of the resolution of their appeal
  • Highly detailed in work habits and products, including investigation of cases and resolution and closure of same
  • Familiarity with medical terminology; ICD-10 Codes
10

Skills For Expedited Appeals Coordinator Resume

  • In Customer Service
  • Manage the corporation’s grievance and appeals database
  • Work with PDF files via the Internet
  • Exhibit a thorough understanding of CMS appeals processing guidelines and Medicare Coverage resources (Medicare Managed Care Manual (MMCM), Benefit Policy Manual (BPM), and Medicare Claims Processing Manual (CPM), Local Coverage Determinations (LCD), National Coverage Determinations (NCD), etc.)
  • Perform comprehensive research related to the facts and circumstances of a member or provider complaint, to include appropriate classification as an appeal and implementation of applicable processes as mandated by CMS

List of Typical Responsibilities For an Appeals Coordinator Resume

1

Responsibilities For Grievance & Appeals Coordinator Resume

  • Facilitates inter-departmental communication related to denial and appeal activity and financial impact
  • Notifies CHS System Director of HIM/CDI/CDM of potential missed timeframes for appeal submission and follow-up on appeal response
  • Provides support for administrative denial management team to facilitate flow of information and receipt of denials and medical records
  • Sound knowledge of Medicaid, Medicare and managed care requirements
  • Competent in preparation and analysis of reports
  • Contact and respond to members and providers within required time frames as required by contracts, regulations and standards
  • Researches and responds to the need for additional information for all medical and behavioral appeal cases received
2

Responsibilities For Claims Audit & Appeals Coordinator Resume

  • Generates and maintains a database of high risk/volume members
  • Responds to phones as assigned, meeting or exceeding the standards for phone access and availability in order to meet the needs of members served by the department
  • Works independently to ensure 100% accuracy of all communications and processes
  • Provides a high level of quality in customer service
  • Logs, tracks, and processes appeals forwarded to the department per line of business
3

Responsibilities For Grievances / Appeals Coordinator Resume

  • Conducts research, requests member records, organizes documentation and prepares written summaries of cases to include the resolutions for appeals when required
  • Maintains all documentation associated with the processing and handling of appeals to comply with regulatory standards while maintaining a complete appeals/grievance record in the electronic database
  • Coordinates review of appeals by preparing the case with all relevant documentation and scheduling the review conducted by the department’s consultant
  • Maintains files for all denial/appeal/reconsideration letters and enters copies of physician referrals into database
  • Coordinates written communication to the UM department
  • Develops and presents ideas to the Supervisor for performance and process management improvement within the department
  • Completes ad-hoc and scheduled reports as requested
4

Responsibilities For Senior Appeals Coordinator Resume

  • Retrieves files and other support materials for client audits
  • Tracks and reports case turnaround time and follows up with the plan, when this requirement is not met
  • Pursue additional payment on low-pay appeals and rebills submitted through various means of communication (telephonically and online) with payers and patients
  • Overcome objections that prevents additional payment of the claim until all attempts have been exhausted
  • Gain commitment for payment through concise and factual collection techniques
  • Communicate trends to management as identified
5

Responsibilities For Medicare Advantage Grievance & Appeals Coordinator Resume

  • Accurate documentation of cases in the appeals management system, maintaining compliance with CMS reporting and data validation requirements. Participate in process improvement meetings and/or discussions, recommending process efficiences. Assist in development of desktop procedures and/or training materials
  • Dockets new appeals and reviews them to identify factual and legal issues, respond to Appellant requests for extension of time, and determine deadlines
  • Achieves and documents early resolution of appeals
  • Tracks and maintains statistics on appeals program workload and performance
  • Receive case documentation from health plan representatives, providers, and members and initiate the appropriate review process
  • Follows up on all retrospective requests to obtain appropriate authorizations. Completes admission authorization process
6

Responsibilities For Utilization Appeals Coordinator Resume

  • Coordinate physician peer to peer conversation to support appropriate level of care
  • Maintains knowledge of payor requirements
  • Familiarity with Internet
  • Drafts appeals decisions
  • Appeals Case Management
  • In Appeals
  • Knowledge in appeals
  • Perform intake, correct and timely classification and routing of all appeal & grievance work types received at the health plan via all methods. Perform routine research and evaluate basic output requirements. Communicate business operational requirements to internal groups responsible for compliant handling. Requires a strong understanding of regulatory definitions and requirements
  • Provide functional support to the appeal processing and clinical review teams. Assist with small to intermediate cross-functional projects and change initiatives involved in the design and delivery of business process solutions, implementation strategies, and control measures and influencing organizational change related to business processes and models

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