Appeals Coordinator

08/08/2007

Triad Healthcare, Inc. is a national company offering full-risk service to develop and manage multi specialty pain management programs. We have a proven track record of providing unique solutions for Group Healthcare, Personal Injury (PIP) and Workers’ Compensation (WC) that mitigate risks and optimize healthcare costs. Our company uses best practices and proprietary software to link payers (carriers), providers (physicians) and patients (members) resulting in operational efficiencies, lower administrative costs and better results for all.
Triad Healthcare is a growing healthcare company in need of a full time Appeals Coordinator. This position is responsible for resolving provider grievances and appeals relative to quality of care, access to care, claim denial and benefit determinations.


Responsibilities Include:

• Compile, track, and trend to identify potential problem areas with providers


• Responsible for coordinating grievance appeals activity and ensuring compliance with State and Federal regulations and accrediting bodies


• Responsible for reviewing correspondence from members requesting to file a grievance


• Coordinate a response to member/provider in compliance with all specified time frames


• Responsible for coordinating the collection of all information and the presentation to the Medical Improvement Committee Quality


• Work closely with Medical Directors on clinical issues to ensure comprehensive appeal investigations
  


• Coordinate outside physician clinical reviews


• Responsible for ensuring that all timeframes throughout the appeals process are met


• Research member/provider information in response to difficult inquiries, including but not limited to authorizations, payments, denials, and coordination of benefits
  


• Work closely with Delivery Team members in obtaining clinical information of appeals for denial of services
  


• Assess, investigate, and resolve difficult issues to achieve member/provider satisfaction
  


• Perform all other duties as required
  

• Associates Degree BA/BS preferred


• Three to five years’ experience in insurance or medical field, preferably in a managed care environment performing claims processing and research functions
  


• Thorough skills knowledge of administrative, claims processing, treatment planning, authorizations and/or customer service functions, (ICD-9) coding, and medical information systems


• Experience in MS Word and Excel


• Excellent communication and written skills


• Regular and predictable attendance

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