Triage and document requests for member appeals, OIC complaints, received via phone, fax, email and mail. Research for cases may involve: medical coverage, claims, authorizations, clinical review, eligibility, and interpretation of legal documents. Provide guidance about appeal process and requirements to members, prospective members, providers, other insurance carriers, agents, brokers, attorneys, employer groups and other member representatives over the telephone or via secure email. Answer high volume of complex verbal communication with members and providers interpreting needs in order to assure a clear and accurate assessment of their issue and assist them in a culturally appropriate manner. Prepare all material for case review in a way that meets regulatory requirements and the needs of the Appeal Coordinator who will investigate and/or consult on the case. Provide ongoing support to Appeal Coordinator.
Setup and prepare electronic case for review by researching claims, authorizations, member contracts, and customer service interactions as well as calling provider office staff to obtain records and billing information. Complex document handling that includes scanning, converting between document types, adobe, redacting, extracting, compressing, secure emailing, secure file transfers, secure faxing. Manage cases without medical issues.
Communicate highly sensitive and confidential information (electronic, telephonic, and written), both into and out of Member Appeal. Responsible for managing all incoming and most outgoing requests, ensuring compliance with timelines and HIPPAA confidentiality requirements
Composes significant amounts of correspondence from templates. Includes confidential information. Proofreads documents for typographical, spelling and content errors. Provide support for the Appeal Coordinators working cases.