About The Role

　　Brighton Health Plan Solutions (BHPS) is seeking an experienced Appeals Coordinator skilled in investigating and resolving grievances, provider payment disputes and medical appeals submitted by our members and providers. Responsible for ensuring all determination responses are compliant with all established regulations.

　　This job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities, and activities may change, or new ones may be assigned at any time with or without notice.

　　Primary Responsibilities

　　Thorough review of claims and medical documentation.

　　Prepare cases for clinical review.

　　Advanced claim processing including professional, facility and ancillary claims.

　　Provide accurate and timely responses to appeals, grievances and all other correspondence.

　　Communicate effectively with individuals/teams to ensure high quality and timely expedition of customer requests.

　　Research and document pertinent information on claims requiring adjudication.

　　Assist Customer Service in responding to and resolving customer questions and concerns related to correspondence.

　　Contribute ideas on ways to resolve problems to better serve the customer and/or improve productivity.

　　Solve problems that are sometimes unstructured and that may require reliance on conceptual thinking.

　　Maintain broad knowledge of client products and services.

　　Essential Qualifications

　　Strong knowledge of contracts, medical terminology, and appeals processing and procedures.

　　Familiarity with computerized medical billing or claims adjudication systems.

　　Previous experience handling appeals and grievances.

　　Excellent written and oral communication, interpersonal and negotiation skills with a demonstrated ability to prioritize tasks as required.

　　Ability to meet expected production standards.

　　Proficient in Microsoft Office Suite- specifically Microsoft Word and Microsoft Excel.

　　Ability to maintain a professional demeanor under pressure.

　　Capable of managing multiple complex issues.

　　Strong knowledge of contracts, medical terminology, and appeals processing and procedures.

　　High School Diploma or GED diploma; some college or business school education is a plus.

　　About

　　At Brighton Health Plan Solutions, LLC, our people are committed to the improvement of how healthcare is accessed and delivered. When you join our team, you’ll become part of a diverse and welcoming culture focused on encouragement, respect and increasing diversity, inclusion and a sense of belonging at every level. Here, you’ll be encouraged to bring your authentic self to work with all of your unique abilities.

　　Brighton Health Plan Solutions partners with self-insured employers, Taft-Hartley Trusts, health systems, providers as well as other TPAs, and enables them to solve the problems facing today’s healthcare with our flexible and cutting-edge third-party administration services. Our unique perspective stems from decades of health plan management expertise, our proprietary provider networks, and innovative technology platform. As a healthcare enablement company, we unlock opportunities that provide clients with the customizable tools they need to enhance the member experience, improve health outcomes and achieve their healthcare goals and objectives. Together with our trusted partners, we are transforming the health plan experience with the promise of turning today’s challenges into tomorrow’s solutions.

　　Come be a part of the Brightest Ideas in Healthcare™.

　　Company Mission

　　Transform the health plan experience – how health care is accessed and delivered – by bringing outstanding products and services to our partners.

　　Company Vision

　　Redefine health care quality and value by aligning the incentives of our partners in powerful and unique ways.

　　DEI Purpose Statement  

　　At BHPS, we encourage all team members to bring your authentic selves to work with all of your unique abilities.   We respect how you experience the world and welcome you to bring the fullness of your lived experience into the workplace.  We are building, nurturing and embracing a culture focused on increasing diversity, inclusion and a sense of belonging at every level.

　　*We are an Equal Opportunity Employer

　　Annual Salary Range: $45,000 - $60,000

　　The salary range and/or hourly rate listed is a good faith determination that may be offered to a successful applicant for this position at the time of the posting of an advertisement and may be modified in the future. When determining a team member's base salary and/or rate, several factors may be considered as applicable by law including but not limited to location, years of relevant experience, education, credentials, skills, budget and internal equity.

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