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.
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
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.