Note: The compensation range(s) in the table below represent the base salaries for all positions at a given grade across the health system. Typically, a new hire can expect a starting salary somewhere in the lower part of the range. Actual salaries may vary by position and will be determined based on the candidate's relevant experience. No employee will be paid below the minimum of the range. Pay ranges are listed as hourly for non-exempt employees and based on assumed full time commitment for exempt employees.

Minimum - Midpoint - Maximum

Summary:

Location: Monarch Place, Springfield MA - Commutable Remote MA/CT only

Schedule: Monday-Friday; Dayshift; 40hrs per week

The Provider Appeals Representative is responsible for the timely review and resolution of post claim review provider appeals, including providing advice and assistance to the Provider Relations Representatives on complex issues. This position will address business problems and issues discovered during the course of an appeal review, and with the help of the Sr. Provider Appeals Representative. Works with other HNE departments to effect changes to HNE policies. The Provider Appeals Representative will propose or suggest training opportunities for other departments on the provider appeals process to the Provider Relations Manager
 

Job Responsibilities:

• Researches, reviews, responds, and recommends action for all provider appeals; work closely with Claims Analyst, Appeals & Policy Nurse, Behavioral Health and appropriate department managers on reviewing appeals and supplying adequate information to make decisions/recommendations as needed
• Communicates with providers and HNE staff to gather info for the decision making process of the appeal. Makes a recommendation for disposition of the appeal and prepare and prepares a response letter, signs decision letters, and handles inquiries from providers.
• Provides education on benefits and/or process to our provider network as well as acting as a resource on complex claim services
• Presents provider education or root cause to cause to Provider Relations Manager
• Acts as a resource for the Provider Relations Representative, Claims, Member Services Departments and Appeals & Policy Nurse with regard to post claim reviews claim reviews, and Provider Appeals database. Coordinates as well as supports efforts with various internal departments
• Works with Provider Relations Manager to identify, suggest, and implement improvements to minimize invalid provider appeals
• Adheres to reporting requirements for DOI, Medicare and Medicaid
• Utilizes the Provider Appeals reporting tool to track appeal turn-around times, outcomes, external review statistics review statistics, etc. to assist other HNE departments
• Adheres to processes around the database to capture trends and data on invalid/valid appeals
• Provides information to provider network on Provider appeals status and determination
• Proactively identifies, suggests. and/or proposes provider network opportunities and training needs
• Identifies, suggests, and implements improvement to Provider Appeals materials on an ongoing basis
• Participates in HNE work groups, committees and projects as assigned
• Works collaboratively with HNE internal departments to ensure-performance guarantees are met
• Serves as back-up on Provider Relations phone queue

Minimum Requirements:

• Associate’s degree and a minimum of 3 years’ experience in a managed care organization
• Demonstrated listening and customer service skills
• Strong verbal and written communication skills
• Problem resolution skills
• Solid interpersonal and negotiation skills
• Strong Multi-tasking and detail oriented skills
• Proficient with the Microsoft suite of products

Preferred Requirements:

• Experience specific to provider relations or complaints & appeals.
• Knowledge of CPT and ICD, DRG and HCPC coding systems as well as industry standard including CMS
• Knowledge of Amisys
• Coding Certified

Health New England is an Equal Opportunity (EEO) employer. It is the policy of the Company to provide equal employment opportunities to all qualified applicants
without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, protected veteran or disabled status, or genetic information.

This position is responsible for maintaining and adhering to internal controls, ensuring compliance with applicable laws and regulations, and following Health New England’s entity level policies and procedures. The position is responsible for reporting unethical or fraudulent activity related to business operations and adhering to Health New England’s Code of Conduct.

Baystate Health is an Equal Opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, marital status, national origin, ancestry, age, genetic information, disability, or protected veteran status.