Job Details

RN Appeals Care Coordinator

Moda Health, Portland, Oregon

Job - Health

Close Date: 07/26/2019

Let’s do great things, together

Founded in Oregon in 1955, Moda is proud to be a company of real people committed to quality. Today, like then, we’re focused on building a better future for healthcare. That starts by offering outstanding coverage to our members, compassionate support to our community and comprehensive benefits to our employees. It keeps going by connecting with neighbors to create healthy spaces and places, together.

We are seeking an RN Appeals Care Coordinator. The RN Appeals Care Coordinator is responsible for providing accurate and appropriate documentation, research and resolution of written and verbal complaints and appeals filed by members, providers and external agencies.

Primary Functions:
01. Resolve clinical member appeals for all lines of business in accordance with state and federal guidelines.
02. Regularly respond to all hearing, appeals, CTM (complaints filed with CMS), grievance, and external review requests within the stipulated time lines and following the review processes outlined in the Managed Care Manuals, Standard Operating Procedures and CMS best practices.
03. Represent Moda Health in administrative law judge hearings (ALJs) as required and give testimony on behalf of the plan.
04. Maintain accurate and timely documentation of all communication, as outlined in the department policies and procedures.
05. Provide oversight of delegated appeals activities to ensure compliance with regulatory and accrediting requirements.
06. Develop professional relationships with internal departments, including effectively communicating with support staff and customer service staff.
07. Contribute to the ongoing efforts of the department to foster a collaborative and team approach to case load.
08. Provide clinical guidance to non-clinical Appeals Team members.
09. Performs other duties as assigned.

Are you ready to be a betterist?

If you’re ready to make a difference that matters, we want to hear from you. Because it’s time to discover what’s possible.

Together, we can be more. We can be better.

Moda Health seeks to allow equal employment opportunities for all qualified persons without regard to race, religion, color, age, sex, sexual orientation, national origin, marital status, disability, veteran status or any other status protected by law.

Complete details: