Company: Magellan Health
Location: San Diego
Posted on: October 12, 2021
Coordinates 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
- 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
- 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
Experience in customer interactions and detailed review of health
Strong interpersonal skills and attention to detail.
Ability to organize work and seek help on tasks where needed.
Strong writing and proofing skills required ensuring documents meet
standards and are accurate.
Work Experience - Required
Work Experience - Preferred
Education - Required
GED, High School
Education - Preferred
Certifications - Required
Certifications - Preferred
Magellan Health, Inc. is proud to be an Equal Opportunity
Employer and a Tobacco-free workplace. EOE/M/F/Vet/Disabled.
Every employee must understand, comply with and attest to the
security responsibilities and security controls unique to their
position; and comply with all applicable legal, regulatory, and
contractual requirements and internal policies and procedures.
Keywords: Magellan Health, San Diego , Appeals Coordinator, Other , San Diego, California
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