Claims
Appeals Coordinator, UM Appeals
Pune, Maharashtra, India

Job title

Appeals Coordinator, UM Appeals

No of yrs. of exp

2

Work Location

Pune

Will the position need US overlap? If yes specify the shift timings

8a-5p EST

 

It’s Time For A Change…

Your Future Evolves Here

Evolent Health has a bold mission to change the health of the nation by changing the way health care is delivered. Our pursuit of this mission is the driving power that brings us to work each day. We believe in embracing new ideas, testing ourselves and failing forward. We respect and celebrate individual talents and team wins. We have fun while working hard and Evolenteers often make a difference in everything from scrubs to jeans.

 

Are we growing? Absolutely. We have seen about 30% average growth over the last three years. Are we recognized? Definitely. We were named one of “Becker’s 150 Great Places to Work in Healthcare” in 2016, 2017, 2018 and 2019 and are proud to be recognized as a leader in driving important Diversity and Inclusion (D&I) efforts: Evolent achieved a 95% score on its first-ever submission to the  Human Rights Campaign's Corporate Equality Index, was named on the Best Companies for Women to Advance List 2020 by Parity.org, and we publish an annual Diversity and Inclusion Annual Report to share our progress on how we’re building an equitable workplace. We recognize employees that live our values, give back to our communities each year, and are champions for bringing our whole selves to work each day. If you’re looking for a place where your work can be personally and professionally rewarding, don’t just join a company with a mission. Join a mission with a company behind it.

 

We are seeking a Grievance and Appeals Coordinator to be a key member of the team. The Grievance and Appeals Coordinator is responsible for receiving, investigating, and resolving member administrative appeals, grievances and provider administrative appeals and supporting the clinical team with clinical appeals.  All tasks will be in compliance with regulatory and accrediting agency standards.

 

Responsibilities: 

  • Receive inbound calls, faxes, emails and mail to initiate an appeal or grievance request utilizing multiple software applications 
  • Make outbound calls when necessary to obtain additional information pertaining to the research of an appeal or grievance 
  • Collect, organize and track information received from a variety of resources to facilitate and expedite the processing of appeals and grievances 
  • Generate acknowledgement letters for member appeals and grievances in accordance with regulatory standards 
  • Initiate, research and resolve member grievances in accordance with company and regulatory standards 
  • Initiate, research and refer member appeals to the Appeals RN 
  • Initiate, research and resolve provider appeals or refer to the Appeals RN, as necessary 
  • Generate resolution letters, as appropriate 
  • Utilize multiple internal and external computer applications and programs 
  • Meet established productivity and quality standards 
  • Perform other duties as assigned 

 

Qualifications: 


Required 

 

  • 2 years of experience minimum in processing appeals and grievances 
  • 3 years of experience within a health plan, managed care organization or third-party administrator 
  • Understanding of appeals process and utilization management 
  • Working knowledge of regulatory and accreditation requirements 
  • Excellent verbal and written communication skills 

 

Preferred 

 

  • Experience in Medicare Advantage plan with knowledge of CMS guidance/regulations for appeal and grievance processing 
  • Bachelor’s Degree 
  • Certified coder 

 

 

Academic Qualification

Bachelor’s degree with nursing focus. 

Work Environment:

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job.  Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. This position primarily works in a climate controlled based setting. The noise level and the work environment are moderately quiet. This role routinely uses standard office equipment such as computers, phones, photocopiers, filing cabinets and fax machines

Physical demand:

Include the physical demands of the job, including bending, sitting, lifting and driving.  For example, while performing the duties of this job, the employee is regularly required to talk or hear.  The employee frequently is required to stand; walk; use hands to finger, handle or feel; and reach with hands and arms.  

Why Join Evolent?

Named among Forbes’ 2014 America’s Most Promising Companies and Glassdoor’s 2015 Best Places to Work, Evolent provides an opportunity to work with top talent in an organization committed to career development. While we come from a variety of backgrounds, we pursue a singular mission: to change the health of the nation by changing the way health care is delivered