Appeals Specialist II

Position Summary

At MedReview, our mission is to bring accuracy, accountability, and clinical excellence to healthcare. As such, we are a leading authority in payment integrity solutions including DRG Validation, Cost Outlier and Readmission reviews. Under the direction of the Appeals Department leaders, the Appeals Coordinator level II team member will assist Appeals leadership with daily administrative work within the department. The Appeals Specialist level II performs research, investigation, and analysis of appeals, grievances, and other types of complaints filed by providers and clients to administer timely resolution. Responsible for all aspects of nonclinical appeals and inquiries

Responsibilities

• This list does not represent all responsibilities for this position. Candidate must understand and be willing and able to assume roles and responsibilities other than these to meet the needs of the department and NYCHSRO/MedReview in general.
• Prepare and disseminate case file for External Reviews and/or State Fair Hearing
• Manage and monitor all appeals from Non-Participating providers
• Independently prepare well written, customized responses to all provider inquiries/complaints that appropriately and completely address the complainant’s issues and are structurally accurate.
• Ensure timely review, research, and resolution of appeals, grievances, and complaints within guidelines. Ensures that all complaints are handled and resolved in compliance with timeliness requirements, and at the highest standards for accuracy
• Consults with managers on problem cases and interfaces with clinical supervisors, account managers, and other personnel in resolving health plan requests or provider inquiries
• Log and track grievances, appeals, and other types of complaints as needed.
• Review and determine outcome of appeal/grievance, either independently or in conjunction with clinical appeal staff.
• Consults with subject matter experts and resources available within organization to assist in appeal and complaint resolution.
• Make critical decisions regarding research and investigation to appropriately resolve all inquiries
• Serve as a liaison to Appeal Coordinator providing guidance and expertise to ensure timely resolution of cases
• Other duties and responsibilities as assigned