Appeals Coordinator (Hybrid)

1199seiu; New York (NY); On-site; USD 70,000 - 100,000; Full time

Job summary

1199SEIU is seeking an Appeals Coordinator to partner with the Manager in achieving department and fund goals. You will guide 1st- and 2nd-level appeals, analyze production metrics, and resolve escalated issues with stakeholders including members, providers, and attorneys.

The role emphasizes compliance with DOL and ERISA, policy improvement, and coaching for staff to ensure accurate determinations and timely responses in a fast-paced environment.

Qualifications

• Bachelor’s degree in health care or related field, or equivalent years of work experience.
• 4+ years’ experience in claims adjudication, health care claims auditing, or benefit administration.
• 2+ years in Healthcare Appeals/Grievances environment preferred.
• Advanced knowledge of QNXT navigation and modules.
• Extensive knowledge of health claims policies and COB rules.
• Intermediate skills in Word and Excel.
• Strong knowledge of Medical Claims Processing Systems (QNXT) and coding (ICD-9/10, CPT).
• Strong critical thinking and analytical abilities.
• Effective verbal and written communication skills.
• Time and project management, detail-oriented, multitasking in fast-paced settings.
• Quality control and auditing procedures experience preferred.

Responsibilities

• Partner with the Manager to implement Appeals Department and Fund goals.
• Serve as a resource on 1st- and 2nd-level appeals for complex cases.
• Evaluate and monitor production, aging, and escalated reports; provide analytical insights.
• Resolve escalated calls and liaise between staff and Management; follow up on urgent matters.
• Daily monitoring of calls; generate reports and coach staff with Listening Sessions.
• Recommend policy/procedure improvements; train staff on updated workflows and compliance.
• Quality reviews with other Appeal Coordinators to ensure audit guidelines and data accuracy.
• Communicate orally and in writing with members, providers, vendors, attorneys, on appeals process and updates.
• Perform additional duties and projects as assigned by management.

Skills

Claims adjudication

Healthcare claims auditing

Benefit administration

Healthcare Appeals/Grievances

MS Word

MS Excel

QNXT navigation

Medical Codes

ICD-9/10

CPT codes

Auditing procedures

Education

Bachelor's degree in health care

Tools

QNXT

Microsoft Word

Microsoft Excel

Job description

• Partner with the Manager to ensure the Appeals Department and Fund goals are implemented, accurately communicated, and achieved.
• Serve as a resource and provide guidance on 1st- and 2nd-level appeals to Appeals staff in the resolution of complex situations.
• Evaluate and monitor daily/weekly/monthly production, aging, and escalated reports and ensure they are acted on timely and appropriately; provide quantitative and qualitative analytical reports to identify trends, objective assessments of strengths or gaps in performance to Manager.
• Resolve escalated calls and act as liaison between Appeals staff and Appeals Management; troubleshoot, resolve, and follow up on urgent matters.
• Conduct daily monitoring of calls using call management systems; generate and review reports for trending system issues, and repeat calls for an improved member experience and report findings to Manager; partner with Manager to conduct Listening Sessions and coaching for phone staff.
• Make recommendations for improvement on policies and procedures for Manager’s approval and partner with Manager to train and develop new or modified policies, procedures, and workflows to ensure compliance with internal and external (Department of Labor (DOL), ERISA, etc.) laws and regulations while providing staff with a roadmap to day-to-day operations.
• Partner with other Appeal Coordinator(s) to conduct quality reviews of Appeals/Inquiries and correspondence to ensure operational procedures and audit guidelines are being followed, identify where there may be a lack of knowledge or re-training if needed (e.g., timely departmental follow-ups, accuracy of response/determination letters, etc.), and ensure accuracy of data and DOL compliance.
• Communicate, oral and written, with members, providers, vendors, attorneys, and other professionals via email, fax, and telephone regarding appeals process, benefits, policies and procedures including plan changes and updates.
• Perform additional duties and projects as assigned by management.

Qualifications

• Bachelor’s degree in health care or related field, or equivalent years of work experience required.
• Minimum of four (4) years’ experience in claims adjudication, health care claims auditing, or benefit administration required, and a minimum of two (2) years of experience in a Healthcare Appeals/Grievances environment preferred.
• Advanced knowledge of QNXT navigation, including all pertinent modules (Member, Claims, Provider, Medical Codes, etc.).
• Extensive knowledge of health claims policies and procedures; eligibility rules, Coordination of Benefits (COB), and 1199SEIU Family of Funds benefits required.
• Intermediate skills in Microsoft Word and Excel required; strong knowledge of Medical Claims Processing Systems (QNXT), medical terminology, ICD 9/10, and CPT codes.
• Strong critical thinking and analytical skills, with effective troubleshooting and problem-solving abilities.
• Effective verbal and written communication skills.
• Effective time and project management skills, with the ability to prioritize, be detail-oriented, multitask, and thrive in a fast-paced environment.
• Demonstrated quality control experience with an understanding of auditing procedures preferred.