Feona I Hammon

o Consults with internal departments such as Clinical, Legal, and Network, as well as company senior management to assure appeal and complaint decisions meet all guidelines and result in customer satisfaction when possible.
o Consults with Account Management and external vendors to resolve high profile, complex appeals and/or complaints.
o Responsible for preparation of written detailed case history and presentation of second level appeal cases to the Appeals Panel for final company determination.
o Documents process and findings within the Appeals and the Complaint databases, and internal systems.
o Responsible for interface with members and providers as required regarding status, process and outcomes of complaints and appeals.
o Responsible for maintaining the integrity of the company relationship with customers by researching, resolving and responding to customer inquiries for appeals, disputes and scheduling issues.
o Responsible for identifying risk situations, consulting with senior management staff and rendering determinations that could adversely affect the company.
o Research, compile, and consult with external review organization and customers as necessary for appeals and complaint process.
o Assist in data gathering and reporting of appeals. Responsible for achieving and maintaining department performance guarantees.
o Assist in developing workflows and innovative process improvements to positively impact the department overall.
o Contributes to unit and department CQI (continuous quality improvement) processes by participating in unit goal setting, scorecard development and departmental meetings. Meets individual performance standards.
o Other duties as assigned as needed.

As an Appeals Coordinator, coordinates timeliness of appeals, grievances, claims, reconsiderations, and appeal recommendation reviews.

• Clinical Support Department report summaries
• Callout Clerks ACD/handle times
• Call monitoring Queue management
• Training of peers
• Audits and error documentation
• Resolution of errors and issues.
• Use of Excel spreadsheets
• Clerk queues
• Supervisor or escalated calls
• Daily reports, Denial meetings with the NIA Doctors re-reviewing denied cases.

Relations with MDO and Remote Doctors to ensure quality and Health Plan guidelines, and Peer to Peer consultation for correction of any errors or changes needed to cases for Members. Also, customer service, fax attachment and case routing.

Duties of Authorization Representative, customer service, problem solving, authorization intake, routing, fax attachment, and documentation of cases.