Medical Management Coordinator (Appeals & UM)

The role of the MMC is to assist analyst with triaging and entering appeals. They will print and assist with medical records request and create overturn notices. They are required to assist with creating shell cases in GuidingCare and create appeal letters.

Intake and case build — MMCs screen all channels daily, return misroutes, confirm member/claim data, and queue clean cases oldest-first.

MMCs issue and track both requests on a fixed cadence, call provider offices on day 3, and index documents in GuidingCare; only non-responsive providers escalate.

MMCs prepare MD and IRO packets and track vendor due dates.

Closure and notification — MMCs route decisions, generate and mail letters and FFRNs, monitor the adjustment queue, and notify providers the day the decision is made.

Must have experience with GuidingCare and FACETS (Legacy and G6)

Good to have LotusNotes and NASCO.

Knowledge of CPT and ICD-10 coding, previous appeals, ability to review letter of appeal, identify claims. Nasco is a plus.