LOCATION: Remote

SALARY: Depending on qualifications & experience of candidate. This position is non-exempt and is eligible for overtime compensation.

GENERAL STATEMENT OF JOB:

This primary purpose of this position is to conduct and support the functions of the Member Appeals Team in managing the peer review, denial and appeal functions for Vaya Health. This position responds to phone calls regarding questions from staff, providers, members, and community members who have questions and needs related to administrative and clinical denials and appeal functions.

Note: This position requires access to and use of confidential healthcare information or protected health information (PHI) as described in laws addressing patient confidentiality, including, but not limited to, the federal HIPAA law, the Confidentiality of Alcohol and Substance Abuse Patient Records law, 42 CFR Part 2, and various state laws. As such, the individual filling this position shall be required to be trained regarding such laws and shall be required to observe those laws in his/her capacity as an employee of Vaya Health. The individual filling this position shall also sign a confidentiality statement as an employee of Vaya Health.

ESSENTIAL JOB FUNCTIONS:

• Prepare, copy and mail denial and appeal notifications Involves writing clinical rationales, validating appeal requests, completing letter templates, verifying accuracy of information, and proofreading correspondence.
• Coordinate and track referrals to Clinical Peer Reviewers
• Prepare and maintain Initial and First Level Denial/Appeal Files
• Prepare and submit denial and appeal information to appropriate spreadsheets and databases
• Responds to phone calls regarding questions from staff, providers, consumers, and community members who have questions and needs related to clinical denial and appeal functions.

Other duties as assigned

QUALIFICATIONS & EDUCATION REQUIREMENTS:

A high school diploma or equivalent is required for this position. Experience in the clerical field is needed for this position. Experience with MH/SA/I-DD services is very helpful but not required. Candidate should be highly organized, detail oriented and able to function well in a faced paced, team environment. Extensive on the job training is required to fulfill the needs of this position. Some of these trainings consist of Medicaid and Non-Medicaid denial and appeal regulations, Excel, ShoreTel phone system, AlphaMCS, Incedo and Vaya internal policy/procedural trainings.

PHYSICAL REQUIREMENTS:

This position must have the ability to establish appropriate and respectful relationships/partnerships with organizational personnel. Ability to work with a multidisciplinary team approach. Ability to assume a helping role and to intervene appropriately to meet the needs of providers, consumers or families served. Works within the established ethical guidelines developed for the profession.

KNOWLEDGE, SKILL & ABILITIES:

Knowledge of and the ability to work a computer and a variety of computer programs is required to perform the requirements of this position as most of the work is electronic. Excellent telephone manners and the ability to work successfully with the public are essential to this position. The ability to establish good rapport with Vaya staff, service providers, and community partners is also expected. Experience in the clerical field is needed for this position. Extensive departmental training is critical to fulfilling the needs of this position. On the job training is required as job duties and processes change frequently.

DEADLINE FOR APPLICATION: Open Until Filled

APPLY: Vaya Health accepts online applications in our Career Center, please visit http://www.vayahealth.com/careers-overview/ Ind.001