"Alerted.org

+ Prepare cases for the clinical team by gathering documentation, loading evidence, and making calls to members and providers.

+ Perform administrative activities including but not limited to generating and printing determination and authorization notification letters.

+ Complete all associated data entry and authorization creation in the True care system.

+ Correctly and completely preps completed case files for clinical review.

+ Notifies team lead of identified patterns of appeals, claim errors, configuration issues or other systemic problems identified during appeal processing.

+ Serves as a liaison in corresponding and communicating with providers and members as needed during appeal processing.

+ Interacts with other departments including Contact Center Operations, Claims, DSE, and E&B to resolve member and provider appeals.

+ Ensures appeals and grievances are categorized and processed within New York state and federal timeframes.

+ Acts/Serves as a liaison between the Health Plan and Member, Members Family and Providers during appeal processing and outcome

+ Prepare evidence packages, makes calls and draft letters as needed.

+ Request denial files from delegated vendors and prepares cases for Clinical Specialist reviews.

+ Maintains file integrity with regards to content and confidentiality.

+ Participate in meetings.

+ Additional duties as assigned.

Minimum Qualifications:

+ HS Diploma or GED

Preferred Qualifications:

+ Bachelors degree

+ Knowledge of related NY state and federal regulations highly desirable

+ Proficiency in Microsoft Office required

+ Knowledge of the New York state ART 44 PHL and federal regulatory environment

+ Knowledge of claims payment process and claims data system (MHS)

+ Ability to work both independently and as a team member

+ Demonstrated ability to be deadline focused and to be flexible in order to adjust to priority changes

WE ARE AN EQUAL OPPORTUNITY EMPLOYER. Applicants and employees are considered for positions and are evaluated without regard to mental or physical disability, race, color, religion, gender, gender identity, sexual orientation, national origin, age, genetic information, military or veteran status, marital status, mental or physical disability or any other protected Federal, State/Province or Local status unrelated to the performance of the work involved.