Full Job Description
At Paramount, we offer insurance to both large and small groups and also cater to Medicare (Paramount Elite) subscribers in northwest Ohio and southeast Michigan. Our Medicaid product (Paramount Advantage) services those living in the state of Ohio. We maintain an accreditation by the NCQA – the National Committee for Quality Assurance – for our Ohio HMO, Elite and Advantage products. We’re also part of ProMedica, which is ranked the second most integrated health system in the U.S. and No. 1 in the Midwest.
Our mission is to improve your health and well-being. So we’re committed to your wellness with various initiatives, such as preventive services, online knowledge, health risk assessments, our Steps2Health disease management programs, health fairs, and more.
The Utilization team is recruiting for an Appeals Coordinator to join the UM Team. The Appeals Coordinator is responsible for the coordination, workflow, and clinical review for provider appeals received at the plan. Supporting Manager / Director in implementation of new processes and workflow for provider appeals. Support Medicaid, ODI, and Medicare regulatory guidance as assigned.
They complete medical necessity review as indicated and process provider appeals based on the request from the provider in cover letter or completed form for final resolution. Work collaboratively with Claims, Provider Relations, or other departments to ensure appeal processed timely and in accord with regulatory requirements / Adjust claims if necessary
Process provider appeals based on appeal type, appeal category, and member implications
Facilitate Medical Director review/appeal determination as necessary / communicate in writing and in accordance with regulatory guidance the appeal outcome
Prepare monthly report(s) for Director / Manager, Utilization Management outlining appeals statistics, as well as analyze for trends and opportunities for UM cost savings and/or provider/staff education. Assure accurate, timely, and appropriate UM appeals reporting
Monitor appeals related to ODM, CMS, ODI, NCQA compliance indicators, and facilitate team processes for compliance of same
Collaborate with the Utilization Management Compliance Coordinator to assure compliance for provider appeals processing and monitoring
Draft and maintain up-to-date departmental appeals procedures
Perform other duties as directed
Education: Associates Degree in Nursing
Experience in a provider setting with demonstrated problem-solving and organizational skills, excellent oral and written communication skills and effective interpersonal skills strongly preferred
Recent experience in public health, managed care, or quality improvement environment required
Ability to develop and present data in meaningful ways to clinical and financial staff
Strong knowledge of governmental regulations related to member/provider appeals and grievances.
Demonstrated ability to handle confidential information in a professional and appropriate manner required.
Demonstrated working knowledge in Word, Excel, Outlook, and internet preferred.
Demonstrated organizational and time management skills.
Must possess the ability to work independently and within a team
Excellent oral and written communication and organizational skills
Ability to plan, coordinate, and organize multiple priorities & exercise independent judgement
Ability to move between company workstations and departments
Ability to communicate on telephones and operate general office equipment, including computers
Years of Experience: Minimum 3 years of relevant RN experience
License: Current Ohio and Michigan nursing license (Michigan registered nurse’s license must be obtained within three months of employment)
Education: Bachelors Degree in Nursing
Years of Experience: 5+ years of relevant RN experience
Qualified applicants will receive consideration for employment without regard to race, color, national origin, ancestry, religion, sex, pregnancy, sexual orientation, gender identity or gender expression, age, disability, military or veteran status, height, weight, familial or marital status, or genetics.
Equal Opportunity Employer/Drug-Free Workplace