Medical Coder Soecialist - Appleas Coordinator
CurrentAudit appeal and grievance files as required by Federal and/or State regulatory agencies and provide feedback, education and training to individual employees to ensure compliance with mandates. Provide written documentation of case determinations to appellants and/or all involved parties (including but not limited to physicians, attorneys, senators/legislators, employer groups, etc.) in a timely manner as required by regulatory mandates and legislation. Initiate claim adjustments on individual cases when necessary and follow and track until completion. Review, analyze and make determinations on provider requests for increased payments related to coding and/or bundling issues. Audit and oversight of entities where delegation of member and provider appeals exists.Identify and take corrective action on appeals or grievances that result from noncompliance of contract provisions, appeal or grievance guidelines, provider contract violations and/or medical policies.Stays current with press releases, emails, and other forms of communications relaying initiatives, contracting issues, as well as Plan wide concerns.Demonstrates high degree of appropriate knowledge of all areas of the plan.Identify and create action plans to educate internal departments on benefit misinterpretation and/or claim payment system errors.Answer member/provider questions via incoming telephone calls in a professional quality driven manner. Handle complaints/grievances as defined by the federal government.
