Quantum Health Careers

Who we are

Founded in 1999 and headquartered in Central Ohio, we’re a privately-owned, independent healthcare navigation organization. We believe that no one should have to navigate the cost and complexity of healthcare alone, and we’re on a mission to make healthcare simpler and more effective for our millions of members. Our big-hearted, tech-savvy team fights to ensure that our members get the care they need, when they need it, at the most affordable cost – that’s why we call ourselves Healthcare Warriors®.

We’re committed to building diverse and inclusive teams – more than 2,000 of us and counting – so if you’re excited about this position, we encourage you to apply – even if your experience doesn’t match every requirement.

About the role

The Appeal Coordinator is responsible for facilitating all appeal requests according to Quantum Health’s defined process for the intake, documentation, preparation, evaluation, and response. This position will work to ensure Department of Labor (DOL) guidelines, Summary Plan Description (SPD) provisions, and guidelines are followed and met.

Location: This position is located at our Dublin, OH campus with hybrid flexibility.

What you’ll do

• Intake appeal and document in PIVIT and Appeal System.
• Read appeal request and any supporting documentation to determine what is being disputed.
• Research applicable SPD provisions, claim processing notes, and collaborate with Third Party Administrator (TPA) partners on reason for claim denial.
• Apply knowledge of the scenario and utilize fact-based decision-making skills and critical thinking to render a determination.
• Utilize approved letter templates to communicate appeal outcomes to members and providers and address any concerns raised in their appeal letter.
• Ensure timely processing and response to all appeal requests to comply with SPD and DOL requirements.
• Collaborate with the Appeal Nurse and/or IRO for all clinical reviews.
• Communicate with member, provider, facility, and all internal work groups regarding appeal requests/outcomes as needed.
• Identify care coordination/referral opportunities and communicate with the pod, warrior for the members.
• Maintain a working knowledge of all appeal processes, workflows, employer benefit plans, and related documentation.
• Serves as the expert on the appeal process by staying current on DOL guidelines, Affordable Care Act, and Federal External Appeal rights.
• Participate in training to educate and coach POD staff regarding the appeal process.
• Collaborate with Client Executives and Client Managers on escalated appeals and SPDs.
• Other duties as assigned

What you’ll bring

• Education: Bachelor’s degree preferred
• 2-years of appeal and grievance experience
• Excellent communication skills (verbal and written) and strong interpersonal skills
• Ability to critically think, exercise excellent independent judgement and decisive decision-making
• Ability to make decisions that are timely and well thought out that achieve results consistent with business goals and organizational culture
• Highly organized and able to work independently
• Takes ownership of assigned duties, projects and goals
• Strong attention to detail
• Ability to take a large number of tasks and prioritize them
• Ability to probe to determine root cause of problems to facilitate appeal reviews and resolve issues
• Strong working knowledge of health insurance coverage, claims, and appeal processes
• Knowledge of Quantum Health, Department of Labor (DOL) time frames for non-certification and appeals
• Knowledge of the specific plan document instructions for non-certification, appeals, and level of appeals available
• Strong overall understanding medical claim processing
• Self-directed, organized with excellent time management skills and limited need for day-to-day supervision
• Computer literacy
• Knowledge of Medical Terminology
• Strong administrative/technical skills; Comfort working on a PC using Microsoft Office (Outlook, Word, Excel, PowerPoint), IM/video conferencing (Teams & Zoom), and telephones efficiently.
• A high degree of personal accountability and trustworthiness, a commitment to working within Quantum Health’s policies, values and ethics, and to protecting the sensitive data entrusted to us.