Appeals Specialist
Martin's Point Health Care
REQ-2020-162
6d ago

Position Summary

The Appeals Specialist (Medicare or US Family Health Plan) is responsible for ensuring

coordination and professional handling of all member appeals, non-participating provider preservice and post-service appeals, and participating provider pre-service appeals in a timely and

compliant manner. The Specialist communicates and collaborates with Case Managers, Medical

Directors and Compliance partners, as well as other internal teams and external partners to

ensure a comprehensive appeals management process.

Job Description

Medicare Focus Key Outcomes :

  • Processes, researches, investigates, and resolves Medicare Part C reconsiderations with 100% compliance.
  • Assists with CMS, NCQA, and Health Plan audit preparation and participates in audits
  • Serve as the Medicare subject matter expert for the Medicare Managed Care Manuals pertaining to Part C appeals
  • Responsible and accountable to meeting 100% timeliness standards in accordance with CMS requirements
  • Cross-trains with US Family Health Plan Appeals Specialist to perform functions as needed
  • US Family Health Plan Focus Key Outcomes :

  • Researches all US Family Health Plan appeals in accordance with Tricare and NCQA guidelines.
  • Presents appeal cases to the Appeals Committee, records meetings, and notifies members of the outcome and creates required reports.
  • Remains current on all issues pertaining to TRICARE and US Family Health Plan benefits, particularly as it relates to Member Appeals
  • Cross-trains with Medicare Appeals Specialist to perform functions as needed
  • Overall Key Outcomes :

  • Prepares appeals documentation within contractual and regulatory requirements, i.e. CMS / DHA / NCQA required forms and letters, request medical records, general correspondence and follow-up.
  • Independently manages multiple work queues consisting of correspondence from providers and members on a daily basis
  • Use critical reading skills to determine the nature of appeals and correspondences and ensure adherence to Standard Operating Procedures (SOP) to determine next steps
  • Evaluate medical claims documentation and coverage policy documentation to determine validity of the appeal
  • Responsible for ensuring and monitoring effectuation of all decisions as a result of the appeal process
  • Brings trends and training opportunities to supervisors and management as appropriate.
  • Works collaboratively and effectively with all other departments and functions to maximize operational efficiency and service and ensure consistency in addressing appeals issues
  • Works with leadership to develop appropriate policies and procedures
  • Maintain confidentiality.
  • Provide quality customer service to internal and external customers.
  • Data entry of appeals to track case details, correspondences, and monitor timeliness of resolution
  • Maintain case files in organized and secure manner, both electronically and written
  • Conduct telephone work with members, providers and third-party administrators.
  • Prepares case files on clinical member and provider appeals for review by clinical team, including medical director.
  • Prepares and sends appeal case files for all appeal levels in accordance with contractual and regulatory requirements
  • Other duties as assigned
  • Education / Experience :

  • Bachelor’s Degree or equivalent experience and education
  • 5+ years experience in managed care plan required; knowledge of Medicare Advantage (for Medicare Specialist) or TRICARE (for USFHP Specialist) appeals processes and regulations strongly 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
  • Excellent organization skills
  • Strong problem-solving techniques
  • 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
  • Solid analytical skills
  • Strong mathematical ability
  • 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 judgment in 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.

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