Physical Health Appeals Coordinator

VIVA USA Inc; United States; Remote; USD 42,000 - 64,000; Full time

Job summary

VIVA USA Inc. seeks a remote-based support specialist to assist members, clinicians, and physicians in processing Physical Health clinical appeals. The role involves inquiries, outbound calls, data entry, and cross-department collaboration to resolve cases.

You will scrub appeals, research next levels of appeal, and liaise with external review bodies when necessary, while upholding HIPAA and company policies.

Qualifications

• 1 or 2 years college OR 3 years of experience with automated systems.
• Experience coordinating member needs and providing assistance to members.
• Knowledge of medical terminology.
• Database experience or PC applications experience.
• Customer service skills; verbal and written communications.

Responsibilities

• Respond to inquiries from members, clinicians, or physicians to support the physical health appeals department.
• Distribute physical health appeals to the Appeals clinicians based on assigned parameters.
• Maintain production requirements based on department needs.
• Support clinical team with non-clinical tasks to generate and close cases.
• Scrub appeals in the MedHoK Appels system and research next level of appeal.
• Upload clinical data to external review organizations when needed.
• Assign and delegate work items received via email or medical management system.
• Communicate professionally with coworkers, management, customers, etc.
• Comply with HIPAA and corporate policies; maintain confidentiality.
• Maintain communication with management and perform special projects as required.

Skills

Customer service

Verbal communication

Written communication

Data entry

Interpersonal skills

Education

Some college coursework (1–2 years)

3 years of experience with automated systems

Job description

BASIC FUNCTION:

Under supervision, this position is responsible for providing support to members, clinicians, and physicians in the processing of Physical Health clinical appeals including responding to inquiries, conducting outbound calls, conducting research, performing data entry, resolving problems by working across departments, and supporting the Physical Health Appeals Department.

ESSENTIAL FUNCTIONS:

1. 1. Receive and respond to customer, clinician, or physician inquiries.Receive and respond to customer, clinician, or physician inquiries to support the physical health appeals department. Required weekend and holiday rotation.Process information from member or provider to determine needs/wants and ensure customer/clinician/physician questions have been addressed. Respond or send to appropriate internal party.
2. 2. Distribute physical health appeals to the Appeals clinicians based on assigned parameters.
3. 3. Maintain production requirements based on established department business needs.
4. 4. Provide support to the clinical team by performing the non-clinical functions necessary to generate and close a case within the platform.
5. 5. Responsible for scrubbing appeals in the MedHoK Appels Application 8. Research next level of appeal and communicate information to the member, provider, and facility when applicable.
6. 6. Responsible for uploading clinical data to any external review organization if needed.
7. 7. Assign and delegate work items received via email and/or medical management system.
8. 8. Communicate and interact effectively and professionally with co-workers, management, customers, etc.
9. 9. Comply with HIPAA, Diversity Principles, Corporate Integrity, Compliance Program policies and other applicable corporate and departmental policies.
10. 10. Maintain complete confidentiality of company business.
11. 11. Maintain communication with management regarding development within areas of assigned responsibilities and perform special projects as required or requested.

JOB REQUIREMENTS:

1 or 2 years college OR 3 years of experience with automated systems. Experience coordinating member needs, providing assistance to members, and analyzing member needs. Knowledge of medical terminology. Database experience or PC applications experience. Customer service skills. Verbal and written communications skills including interpersonal skills to assist members and coordinate care with physician offices, developing written correspondence to members and to other department personnel, and to support departmental personnel and functions.

BASIC FUNCTION:

Under supervision, this position is responsible for providing support to members, clinicians and physicians in the processing of Physical Health clinical appeals including responding to inquiries, conducting outbound calls, conducting research, performing data entry, volume management, productivity tracking, resolving problems by working across departments, and supporting the physical health appeals department.

Notes:

Fully remote opportunity available to applicants in any of our U.S. States except NY, CA, and AK

This is a contract role with the possibility of conversion to full-time based on business needs and performance

This is a M-F shift 40 hours per week, with MANDATORY holiday and weekend rotations. Holidays rotation includes 3-4 assigned holidays per year and one weekend every 3rd weekend - assigned rotation.

VIVA is an equal opportunity employer. All qualified applicants have an equal opportunity for placement, and all employees have an equal opportunity to develop on the job. This means that VIVA will not discriminate against any employee or qualified applicant on the basis of race, color, religion, sex, sexual orientation, gender identity, national origin, disability or protected veteran status