Provider Appeals Coordinator

About Our Company
We are a company built on excellence. We have a culture that values growth, achievement and diversity and a workplace where your voice can be heard.

JOB MISSION SUMMARY

Risk Management is charged with protecting company assets. This group is responsible for minimizing risk in legal, financial and operational areas and its affects on the organization, as well as for enforcing security and safety measures.

RESPONSIBILITIES
- Reviews provider appeal file when received from intake coordinator
- Determines the research necessary to facilitate appeal resolution, contacts provider as appropriate
- Process all appeals within regulatory timeframes and in a manner consistent with regulatory requirements for Division of Developmental Disabilities (DDD), Arizona Long Term Care System (ALTCS), Acute and Medicare lines of business
- Researches relevant claims for appropriate processing
- Uses available tools for research, such as the state s system (DOA), AHCCCS web site, CMS web site, Encoder Pro, claims mail back database, MDR and QMACS to determine if claim processed appropriately
- Researches benefits for all lines of business as appropriate
- Tracks appeals to determine potential system issues, staff education or provider education opportunities, and reports potential issues to supervisor or manager
- Determines if appeal must be routed to medical management and forward as appropriate
- Prepares cases to the IRE for denied non-par provider appeals in compliance with IRE regulatory requirements, including compiling a narrative explaining decision rationale



Required Skills:
REQUIRED SKILLS
- Minimum of two years of recent and related experience working within a billing, claims, customer service, health care provider, health regulator or health insurance environment.


Schaller Anderson is an affiliate of Aetna.  We value leadership, creativity and initiative. If you share those values and a commitment to excellence and innovation, consider a career with our company.

To learn more about this opportunity, visit us at www.aetna.com/working 23842

Please note that benefit eligibility may vary by position. Click here to review the benefits associated with this position.

We conduct pre-employment drug and background testing.
No agencies, please.


We are an equal opportunity/affirmative action employer.