Glen Allen VA 23060 Suite 125
Job DescriptionCoordinates appeals process as assigned, attends to risk management issues associated with case management and processes appeal requests. In some cases may be combined with Grievance Coordinator functions.
- Maintains a caseload and monitors day to day compliance of appeal decision time frames.
- Reviews clinical and medical records for completeness and determines administrative or clinical appeal.
- Assigns reviews to physician advisers and medical directors for those requiring medical necessity reviews.
- Enters all data related to appeals and case reviews into a database.
- Prepares and presents information on appeals to panels second-level multi-disciplinary committee.
- Participates in data gathering and analysis of reports regarding appeal activity as well as preparing for appeals audits, provides new employee training, monitors QI (Quality Improvement) activities of appeals department, and assists in the development of depart flows and implementations.
- Coordinates and distributes first, second and third level appeal request assignments.
- Consults with managers on problem cases and interfaces with case managers, clinical supervisors, account managers and other personnel in resolving denial and appeal questions.
- Responds to member, provider, and client telephone inquiries regarding status, process and outcome of appeals.
- Organizes volume of work and work-flow so that performance standards and proper procedures for appeals resolution according to client requirements and state and federal regulations are addressed.
General Job Information
Job FamilyQuality Group
CountryUnited States of America
FLSA StatusUnited States of America (Non-Exempt)
Recruiting Start Date2/13/2020
Date Requisition Created2/12/2020
Work ExperienceCustomer Service
EducationGED (Required), High School (Required)
License and Certifications - Required
License and Certifications - Preferred
Other Job Requirements
- 2+ years experience in processing appeals and/or claims.
- Experience working in a contact center environment.
- 2+ years Behavioral Health, Healthcare or Managed Care Industry experience.
- Ability to talk on the telephone and type on a computer simultaneously.
- Working knowledge Microsoft Product Suite.
- Ability and willingness to learn new software applications.
Magellan Health Services is proud to be an Equal Opportunity Employer and a Tobacco-free workplace. EOE/M/F/Vet/Disabled. Every employee must understand, comply and attest to the security responsibilities and security controls unique to their position.
Top 5 reasons to work at Magellan
Meaningful Work With People Who Care
At Magellan Health you can do meaningful work and feel confident that you matter in an organization that makes a real difference in the world - one that cares deeply and uses its employees’ collective insight as a competitive advantage.Read More
We are Compassionately Curious
Magellan Health is a place where we listen with real empathy. It’s one of our biggest strengths. It helps us to support each other and develop innovative solutions for the fastest growing, most complex areas of healthcare.Read More
We are Better Together
We rely on our innate ability to work as a high-functioning collaborative team to facilitate compassionate care to all of our members. With such interdependency comes trust, challenge and innovation.Read More
We believe work and life should flow together in unison. We offer resources that match your professional development, a culture that welcomes your ideas, and unparalleled flexibility to fit work around your life.Read More
Be your best at Magellan Health. We’re a collective of remarkably motivated and driven professionals. As a team, we’re proud of the high standards we set for each other and we’re continually inspired to do our best work.Read More
When you sayLife @ Magellan
To be the best you have to work with the bestWe hear you