To protect the health and well-being of our members, employees and community, CareOregon requires all employees to be fully vaccinated against COVID-19 or have an approved medical or religious exception as a qualification of employment.

Candidates who receive an offer of employment by CareOregon, must provide proof of COVID-19 vaccination or submit a medical or religious exception request, which will be evaluated in accordance with CareOregon’s standard accommodation process.

Position Title Appeals Coordinator

Department: Health Plan Quality Assurance

Title of Manager: Quality Assurance Supervisor

Supervises: Non-supervisory position

Exemption Status: Non-Exempt

Work Hours: Monday – Friday, 8:00 AM to 5:00 PM

Requisition ID: 22164

**This position is a benefitted 40 hour per week contingent position with a projected 6-month assignment duration.

General Statement of Duties

This position is responsible for coordinating appeals, including tracking, documentation, collection, and file maintenance with strict compliance to State and Federal regulatory requirements. This position communicates with members, internal and external customers in matters relating to appeals.

Essential Position Functions

• Document and track all appeals and any activity pertaining to them.
• Request additional information for use in resolving appeals from CareOregon departments as needed.
• Follow up on necessary actions to ensure strict compliance with State and Federal regulatory requirements.
• Maintain files on each appeal in detail to allow for easy independent review of documentation.
• Correspond verbally and in writing with members and physicians to gather supporting documentation to assist in resolution of appeals and to provide status updates as needed.
• Assemble all relevant evidence for reviews/hearings as appropriate.
• Identify cases that require review by the various departments, including but not limited to Medical Management.
• Ensure that all relevant materials are forwarded to appropriate departments for the review process.
• Collaborate with designated CareOregon representative to DMAP hearings.
• Provide defined support functions to assigned CareOregon committees.
• Provide technical processing training and assistance to CareOregon employees as necessary and appropriate related to appeals/grievances.
• Demonstrate initiative in seeking and understanding needed information about policies and procedures.

Essential Department and Organizational Functions

• Propose and implement process improvements.
• Meet deadlines for completion of workload.
• Maintain agreed upon work schedule.
• Demonstrate cooperation and teamwork.
• Provide cross-training on specific job responsibilities.
• Meet identified business goals that contribute to departmental goals.
• Perform other duties as needed.

Knowledge, Skills and Abilities Required

• Knowledge of medical and health insurance terminology
• Understanding of State/Federal laws and other regulatory agency requirements that relate to the medical health insurance industry or Medicaid/Medicare industry
• Ability to proactively identify ways to improve quality and productivity and reduce appeals/grievances
• Strong analytical skills
• Ability to develop, track and implement projects meeting deadlines and project goals
• Ability to work with the department, stakeholders or customers to effectively resolve issues
• Ability to develop and implement processes and procedures
• Ability to work in an environment with diverse individuals and groups
• Strong computer application skills including MS Windows, Word, Excel and Outlook
• Strong interpersonal and communication skills (both verbal and written)
• Strong customer service and problem-solving skills
• Ability to type a minimum of 40 words per minute
• Superior detail orientation and time management skills
• Strong organization and project management skills
• Possess a high degree of initiative and motivation
• Ability to effectively collaborate and plan with coworkers and others

Physical Skills and Abilities

Cognitive and Other Skills and Abilities

Ability to focus on and comprehend information, learn new skills and abilities, assess a situation and seek or determine appropriate resolution, accept managerial direction and feedback, and tolerate and manage stress.

Education and/or Experience

Minimum 1 year experience working with appeals and grievances or high level customer service experience. Health plan experience preferred.

Working Conditions

• Environment: This position’s primary responsibilities typically take place in the following environment(s) (check all that apply on a regular basis):

• Inside/office Clinics/health facilities Member homes

• Other_________________________________________

• Travel: This position may include occasional required or optional travel outside of the workplace, in which the employee’s personal vehicle, local transit, or other means of transportation may be used.
• Equipment: General office equipment
• Hazards: n/a

Candidates of color are strongly encouraged to apply. CareOregon is committed to building a linguistically and culturally diverse and inclusive work environment

Veterans are strongly encouraged to apply.

Equal opportunity employer. This company considers all candidates regardless of race, color, religion, sex, sexual orientation, gender identity, national origin, disability or veteran status.