Clinical Appeals Coordinator

Job Description

Strength Through Diversity

Ground breaking science. Advancing medicine. Healing made personal.

 

Roles & Responsibilities:

 

1. Logs, tracks, and processes health service appeals. 
2. Serves as a liaison in corresponding and communicating with providers and members or members' representatives as needed during appeal processing. 
3. Interacts with office staff and other departments (such as case management) on an as needed bases to resolve any issues that may arise during the appeal process 
4. Makes administrative appeal determinations when indicated and properly sets up case files for clinical review when needed. 
5. Conducts general appeal research and filing including, but not limited to, organizing documentation, preparing written appeals, preparing PRC (peer review committee) summary forms and sending completed case files to external review organizations as required by regulatory guidelines. 
6. Maintains all documentation associated with the processing and handling of appeals to comply with regulatory standards and timeframes while maintaining an accurate, complete appeals record in the electronic database. 
7. Performs administrative activities including, but not limited to, generating, printing and mailing determination and authorization notification letters. Completes all associated data entry in department systems. 
8. Develops and presents ideas for performance and process management improvement within the department. Notifies Supervisor or other appropriate parties of identified patterns of appeals, claim errors, configuration issues, or other systemic problems identified during appeal processing.
9. Performs special projects as needed.

 

Requirements:

BA/BS required 

 

 

Strength Through Diversity

 

The Mount Sinai Health System believes that diversity and inclusion is a driver for excellence. We share a common devotion to delivering exceptional patient care. Yet we’re as diverse as the city we call home- culturally, ethically, in outlook and lifestyle. When you join us, you become a part of Mount Sinai’s unrivaled record of achievement, education and advancement as we revolutionize healthcare delivery together.

 

We work hard to recruit and retain the best people, and to create a welcoming, nurturing work environment where you have the opportunity and support to develop professionally. We share the belief that all employees, regardless of job title or expertise, have an impact on quality patient care. 

 

Explore more about this opportunity and how you can help us write a new chapter in our story! 

 

Who We Are

 

Over 38,000 employees strong, the mission of the Mount Sinai Health System is to provide compassionate patient care with seamless coordination and to advance medicine through unrivaled education, research, and outreach in the many diverse communities we serve.

 

Formed in September 2013, The Mount Sinai Health System combines the excellence of the Icahn School of Medicine at Mount Sinai with seven premier hospitals, including Mount Sinai Beth Israel, Mount Sinai Brooklyn, The Mount Sinai Hospital, Mount Sinai Queens, Mount Sinai West (formerly Mount Sinai Roosevelt), Mount Sinai St. Luke’s, and New York Eye and Ear Infirmary of Mount Sinai.

 

The Mount Sinai Health System is an equal opportunity employer. We promote recognition and respect for individual and cultural differences, and we work to make our employees feel valued and appreciated, whatever their race, gender, background, or sexual orientation. 

 

EOE Minorities/Women/Disabled/Veterans


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