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Appeals Coordinator

HealthSun Health Plans • Miami, FL

Posted 7 days ago

Job Snapshot

Travel - None
Experience - At least 1 year(s)
Degree - High School
Healthcare - Health Services
Health Care


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Job Description

HealthSun Health Plans is seeking energetic,talented and qualified professionals to join us in our mission of changing the healthcare experience of our members - making it easier, friendlier and more accessible.  If you are looking for a challenging and rewarding career with a chance to make a real difference in your community, please apply.

HealthSun Health Plans is headquartered in the Coconut Grove area of Miami, Florida supporting the needs of Medicare Advantage recipients throughout South Florida. We are proud to offer outstanding career advancement opportunities, competitive salaries, paid holidays, medical & dental insurance plans, Paid Time Off, disability benefits, and a 401(k) retirement savings plan.

The Appeals Coordinator is responsible for the accurate and timely processing of all Medicare Advantage and Medicare Part D appeals within strict Medicare regulatory guidelines.

Essential Duties & Responsibilities:
  • Receives and sorts all mail/correspondence pertaining to the appeals department (faxes, claims mail, appeals mail.
  • Screens each case file to establishes and identify the appropriate course/process for the case file 
  • Appropriately identifies cases that should be expedited and processed accordingly (Monitors the Expedited Appeal line as assigned.
  • Prioritizes caseload to meet strict regulatory time frames.
  • Processes all appeals within regulatory guidelines, including but not limited to contacting enrollees and providers, researching Medicare rules and regulations, reviewing claims, authorizations/referrals, contracts, medical records and legacy system documentation.
  • Presents case file to Medical Management/Medical Director for preliminary review.
  • Delegates case file to Medical Management for authorization/referral  Effectuation.  
  • Delegates case file to Claims Department for payment.
  • Appropriately communicates to all parties, including but not limited to, verbal communications and use of approved letters and notices.
  • Prepares and submits case files to IRE as required under the regulations and serves as IRE main contact for each case file submitted.
  • If summoned, participates in Administrative Law Judge Hearings, Judicial Hearings and MAC Hearings  
  • Ensures complete and accurate documentation in system and case files.
  • Maintains appropriate and up to date knowledge of Appeals guidelines established by the CMS and working knowledge of Medicare regulations in general.
  • Identifies any trends or issues of concern and addresses them with the Appeals manager and/or Medicare Compliance Officer.
  • Maintains strong working relations with all internal and external parties.
  • Communicates effectively with other professional and support staff in order to achieve positive customer outcomes.
  • Promotes and contributes to a positive, problem-solving environment.
  • Assists customers, family members and others with concern and empathy; respect their confidentiality and privacy and communicate with them in a courteous and respectful manner.
  • Complies with company policies and procedures and maintains confidentiality of customer medical records in accordance with state and federal laws.
  • Ensures compliance with all HIPAA, OSHA, and other federal, state, and local regulations. 
  • Participates in meetings, training and in-service education, as required. 
  • Performs other duties as assigned.

Job Requirements

  • Minimum of High School diploma or equivalent
  • Associate’s degree in Health Services or related field from an accredited college or university is preferred
  • Minimum of 1 year experience in healthcare setting required
  • Working knowledge of the Privacy and Security Health Insurance Portability and Accountability Act (HIPAA) regulations
  • Excellent communication skills, attention to detail, ability to set priorities appropriately and meet strict deadlines and the ility to manage multiple tasks simultaneously is required
  • Excellent listening, interpersonal, verbal and written communication skills with individuals at all levels of the organization
  • Excellent computer knowledge is required, including proficient knowledge of Microsoft Office
  • Familiarity with healthcare laws, regulations and standards
  • Must be patient in dealing with an elderly population and sympathetic to hearing or vision deficiencies
  • Ability to work effectively independently and in a team environment
  • Ability to read, analyze, and interpret technical procedures or governmental regulations
  • Ability to write reports, business correspondence, and procedure manuals
  • Ability to effectively present information and respond to questions from groups of managers, clients, customers and the general public
  • Ability to calculate figures and amounts, such as discounts, interest, commissions, proportions, percentages, area and volume
  • Ability to define problems, collect data, establish facts, and draw valid conclusions
  • Strong decision-making, analytical skills
  • Must be self-motivated, organized and have excellent prioritization skills
  • Must be able to work well under stressful conditions
  • Must be able to work in a fast paced environment
  • Fluency in Spanish and English required

HealthSun Health Plans and its affiliated companies is an equal opportunity/affirmative action employer and complies with all federal and state laws, regulations and executive orders regarding affirmative action requirements in all programs.M/F/D/V.

HealthSun and its affiliates are also a drug-free workplace.

*Internal candidates must submit the Internal Application Form approved by his/her supervisor before interviewing with HR. Qualified candidates will be considered by the Hiring Manager.
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