Clinical Appeals Coordinator

Company Overview:

Cohere Health is a fast-growing clinical intelligence company that’s improving lives at scale by promoting the best patient-specific care options, using leading edge AI combined with deep clinical expertise. In only four years our solutions have been adopted by health insurance plans covering over 15 million people, while our revenues and company size have quadrupled.  That growth combined with capital raises totaling $106M positions us extremely well for continued success. Our awards include: 2023 and 2024 BuiltIn Best Place to Work, Top 5 LinkedIn™ Startup, TripleTree iAward, multiple KLAS Research Points of Light, along with recognition on Fierce Healthcare's Fierce 15 and CB Insights' Digital Health 150 lists.

Opportunity Overview:

Last but not least: People who succeed here are empathetic teammates who are candid, kind, caring, and embody our core values and principles. We believe that diverse, inclusive teams make the most impactful work. Cohere is deeply invested in ensuring that we have a supportive, growth-oriented environment that works for everyone.

What you will do:

• We are seeking a talented Clinical Appeals Coordinator who will be responsible for responding to written/verbal appeals and disputes submitted by members and providers in accordance with NCQA, CMS, State, and other regulations. They will process appeals to facilitate the accurate administration of benefits and clinical policy; and ensure compliance of the appeal process with all regulatory requirements and NCQA standards. This individual will work as an effective interface between internal and external customers and maintain provider relations.

Responsibilities

• Comprehensively review and evaluate appeal and grievance requests to identify and classify member and provider appeals. Determine eligibility, benefits, and prior activity related to the claims, payment or service in question.
• Provide written acknowledgment of member and provider correspondence.
• Responsible for making verbal contact with the member or authorized representative during the research process to further clarify, as needed.
• Conduct thorough investigations of all member and provider correspondence by analyzing all the issues involved and obtaining responses and information from internal and external entities.
• Serve as liaison with internal Cohere departments, delegating Client entities, medical providers and physicians to ensure timely resolution of cases.
• Research appeal files for completeness and accuracy and investigate deficiencies. Consult with internal areas as required to clarify legal ramifications around complex appeals.
• Follow-up with responsible departments and delegating entities to ensure compliance.
• Accurately and completely prepare cases for medical and administrative review detailing the findings of their investigation for consideration in the final determination.
• Monitor daily and weekly pending reports and personal worklists, ensuring internal & regulatory timeframes are met.
• Responsible for monitoring the effectuation of all resolution/outcomes resulting from internal appeals as well as all appeals reviewed through the IRE (Medicare).
• Identify areas of potential improvement and provide feedback and recommendations to management on issue resolution, quality improvement, network contracting, policies and procedures, administrative costs, cost saving opportunities, best practices, and performance issues.
• Prepare written responses to all member and provider correspondence that appropriately address issues and are structurally accurate.
• Ensure documentation requirements are met: create and document service requests to track and resolve issues; document final resolutions along with all required data to facilitate accurate reporting, tracking and trending.
• Perform other duties as assigned or required.
• Regular attendance is an essential function of the job.
  

Your background & requirements:

• Associate Degree in Nursing or other healthcare area; Bachelor’s preferred
• 3+ years of related professional work experience required
• Excellent verbal and written communications skills required
• Ability to comprehend and produce grammatically accurate, error-free business correspondence required
• Excellent problem solving and analytical skills required
• Ability to work under pressure and deliver complete, accurate, and timely results required
• Excellent organization and time management skills required
• Customer service experience preferred
• Knowledge of NCQA standards preferred
• Prior healthcare industry and/or compliance work experience preferred
• Experience in a managed care/compliance environment preferred

We can’t wait to learn more about you and meet you at Cohere Health!

Equal Opportunity Statement: 

Cohere Health is an Equal Opportunity Employer. We are committed to fostering an environment of mutual respect where equal employment opportunities are available to all.  To us, it’s personal.

The salary range for this position is x to y annually; as part of a total benefits package which includes health insurance, 401k and bonus. In accordance with state applicable laws, Cohere is required to provide a reasonable estimate of the compensation range for this role. Individual pay decisions are ultimately based on a number of factors, including but not limited to qualifications for the role, experience level, skillset, and internal alignment.

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