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Quality Coordinator - Denials & Appeals in Rocky Hill, CT at Beacon Health Options

Date Posted: 1/14/2019

Job Snapshot

Job Description

We are currently seeking a dynamic Quality Coordinator - Denials & Appeals to join our team at our office in Rocky Hill, CT!  The Quality Coordinator assists with the development, implementation, monitoring and analysis of appeals and retrospective requests processes and activities. Ensure that contractual timeframes are maintained. Manage, analyze and report on member and provider medical necessity appeal process. Assist with the log, investigation and setting up of the review for higher level of care retrospective reviews.  Initiates all correspondence related to administrative and medical necessity denials. Provide overall project support for the staff of the Connecticut Behavioral Health Partnership (CT BHP) Quality Management (QM) Department. Project support includes the coordination of quality improvement initiatives; and activities related to member appeals, retrospective chart reviews for quality, the support of the CT BHP quality infrastructure, and preparing and reporting on numerous aspects of quality. 

Position Responsibilities:

Develop, implement and revise, as necessary, policies, procedures, and workflows for appeals and retrospective reviews pursuant to revisions in health care accrediting standards, laws, regulations and client contract requirements.

Coordinates the creation of all denial letters for both administrative and medical necessity denials.  Log and track when letters are sent out to members and providers.  Comply with performance standards set by the contact relative to the issuing of the denial letters and notifies senior management when performance standards are not met.      

Coordinates the overall process for Administrative and Medical Necessity appeals; log, track, and investigate appeal requests.  Coordinates with local and National Medical Directors to review Medical Necessity appeal requests.  Compiles Administrative Appeal requests with rationales and conducts necessary research in preparation for the Administrative Appeal meetings.  Complies with performance standards set by the contact relative to the timeframes within which appeals need to be resolved and notifies management when the timeframes are not met.  Proactively identifies issues and/or trends requiring the attention of the Partnership’s senior management and facilitates their resolution.

Assist in preparing semi-annual and annual evaluations of the Service Center QM program and plan.  Assists in the development of the QM annual work plan.  

Prepare written assessment reports that describe results, operational strengths, opportunities for improvement and recommendations.

Utilize basic statistical concepts to evaluate the validity of findings and their applicability to quality and risk management processes and activities.

  1. Manage and report on member and provider medical necessity appeals.
    • Maintenance of the Appeals database
    • Documentation of Appeals in database
    • Assist members and providers as needed in the Appeal Process
    • Interface with Clinical department around scheduling MD reviews and determination documentation in CareConnect
    • Interface with the Provider Relations Department on provider Administrative Appeals
    • Timely notification of determinations to members and providers

Provide general administrative and basic project management support as well as development, management, analysis to initiatives related to the improvement of the quality of the CT BHP services and operations.

Provide support to the quality management infrastructure in the collection of policies, procedures and committee minutes and ensure their posting to the CT BHP intranet.

Position Requirements:

Education: BA preferred, human service background preferred.

Relevant Work Experience:   3 years’ work experience, either in a customer service or in a human service setting

Knowledge, Skills & Abilities:

  • MS Office:Outlook, Word, Excel, PowerPoint, Access

  • Analysis and problem solving skills

  • Interpersonal communication

  • Verbal & written communication skills

  • Collaboration and team-oriented work philosophy

  • Organizational and follow-up skills

  • Ability to balance multiple priorities and manage deadlines

  • Ability to exercise good judgment and discretion

  • Demonstrated ability to interact effectively with a broad cross-section of

    the population, including, but not limited to, senior managers, providers,

    staff, and consumers

  • Strong English language speaking skills

  • A second language is desirable, especially Spanish


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Beacon Health Options company is proud to be an Equal Opportunity and Affirmative Action Employer as well as a Drug Free and Tobacco Free Work Environment. EOE/AA/M/F/Veterans/Disabled