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Position Summary
Medicare and US Family Health Plan (USFHP) Appeal Specialists are responsible for processing of all member appeals, non-participating provider pre- and post-service appeals, and participating provider pre-service appeals. The Specialists collaborates with Care Managers, Medical Directors and Compliance partners, as well as other internal and external partners to ensure a comprehensive appeals management process.Job Description
Key Outcomes:
- Demonstrates advanced knowledge and expertise in processing both Generations Advantage and US Family Health plan appeals and grievances. This includes expertise in case classification, including organization and coverage determinations for both lines of business.
- Demonstrates advanced knowledge of claims processing and health plan benefits necessary for the Appeals Specialist to exercise decision-making authority to reprocess claims in accordance and alignment with regulatory and internal policies.
- Independently and with judgement, conducts multi-faceted, complex investigations through claims review, provider credentialing, authorization processing, timeliness evaluations, and plan benefits design.
- Maintains and manages multiple work queues in alignment with regulatory timeframes and internal performance policies. These include inbound mail, fax, voicemail, internal communication platforms and an electronic Appeals management system.
- Responsible for all written and verbal communication with external downstream-entities, provider offices, customers and internal business partners appeals related asks.
- Drafts and issues regulatorily compliant communications requiring advanced knowledge necessary to analyze, interpret and respond promptly to the requests based on facts and circumstances of the case.
- Responsible for call case file creation, management and oversight of case submission to required review entities (i.e. QIO, DHA, etc.).
- Serves at the key contact for these entities related to each case submitted. This work includes the monitoring and tracking to case completion.
- Prepares files and participates in both internal and external auditing activities. These reviews may include activities like the Defense Health Agency (DHA) Annual review, NCQA certification audit, CMS Data Validation audits or CMS Full Program audits.
- Prepares files for second level appeals through DHA or ALJ.
- Cross departmental support for training and workflows associated with complex appeals processing, including health plan appeals training, appeals trend reporting and general appeals oversight.
- Skillfully conducts provider and beneficiary outreach for the purposes of investigation and resolution of appeals, including outreach to provider billing offices and facilities.
- Independently reviews/updates policies, procedures, forms, workflow and letter templates on semi-annual basis.
- Evaluates and implements process improvements and operational efficiencies associated with case classification and appeals processing.
- Participates and conducts internal system upgrade testing to include support annual benefit development and implementation of regulatory changes when they occur as it relates to the appeals process.
- Serves as daily resource for staff and partner department questions and appeals related escalations.
- Serves as the subject matter expert for TRICARE and US Family Health Plan manuals related to appeals, as well as CMS Part C and Part G Organization Determinations and Grievances guidance.
- Independently partners with Medical Directors and other clinical support staff on appeals requiring clinical decision making determinations.
- Maintains responsibility to maintain timeframe requirements on decision making and communication processes after-hours and during holidays to maintain all regulatory and statutorily required timeframes.
Education/Experience:
- Bachelor’s Degree or equivalent experience and education
- Knowledge of Medicare Advantage and/or TRICARE appeals processes and regulations strongly preferred
- 5+ years’ experience in managed care plan preferred
Skills/Knowledge/Competencies (Behaviors):
- Demonstrates an understanding of and alignment with Martin’s Point Values.
- Excellent written and verbal communication skills
- Effective time management skills and organization skills
- Must have a track record of producing high-quality work: highly accurate, demonstrates attention to detail, and reflects well on the organization
- Strong interpersonal skills and the ability to collaborate with internal and external clients
- Excellent customer services skills
- Strong analytical, problem-solving and mathematical skills
- Proficiency in Microsoft Office applications (Word, Excel, PowerPoint)
- Strong organizational skills and able to meet deadlines (ability to prioritize and multi-task while maintaining focus on objectives).
- Self-driven and self-motivated: ability to function independently with sound decision making
- Take appropriate initiative while soliciting input/advice appropriately
- Ability to handle confidential and sensitive information in a discreet and professional manner.
- Ability to handle high volume of work while maintaining accuracy and timeliness requirements
We are an equal opportunity/affirmative action employer.
Do you have a question about careers at Martin’s Point Health Care? Contact us at: jobinquiries@martinspoint.org