Appeals Specialist

Jefferson Health Plans • Philadelphia, PA

21h • Onsite

About The Position

The Appeals Specialist is responsible for independently coordinating Medicaid & CHIP Standard and Expedited Complaints and Grievances from receipt to resolution. The Appeals Specialist must have a broad knowledge of products and benefits as well as understand regulatory requirements and timeframes.

Requirements

• Bachelor’s degree or paralegal preferred
• 3-5 years of experience in processing Medicaid and/or CHIP Complaints and Grievances or a concentration in compliance, legal, or quality management
• Strong communication (written/oral) and organization skills with a great level of attention to detail.
• Ability to interpret medical terminology and regulations to apply them without direct supervision.
• Exceptional customer service and presentation skills.
• Exceptional productivity, autonomy, and initiative.
• Ability to handle multiple responsibilities and changing priorities.
• Advanced knowledge of Microsoft Office (Excel and Word), CCMS, MACESS, and relational databases.

Responsibilities

• Keeps current with all rules, regulations, policies, and procedures relevant to the Complaints, Grievances, and Appeals Unit.
• Must have a thorough understanding of Health Plan operations and business unit processes, workflows and system requirements, including but not limited to, authorizations, billing, regulatory compliance, and plan benefits.
• Work closely with Medical Directors and other Health Plan staff to resolve Grievances (i.e.) appeals timely and accurately.
• Manages case load, multiple systems, and plans appropriate allocation of resources to provide quality assessment of assigned Complaints and Grievances.
• Handles multiple issues and prioritizes appropriately with the ability to organize work to meet deadlines.
• Develops and maintains collaborative relationships with internal and external customers.
• Performs outreach calls to members, head of household, and authorized representatives.
• Ensures the timely and accurate review, routing, and tracking of member Complaint and Grievance issues in compliance with Medicaid and CHIP requirements.
• Identifies and analyzes various member issues/concerns and ensures well documented resolution(s) of the same are entered real-time.
• Interpret member benefit limit exceptions and denial information in order to clearly communicate and manage expectations.
• Outreaches to provider offices to obtain responses to member complaints involving primary care physicians, specialists, hospitals, ancillary services/durable medical equipment, delegated vendors, and their staff.
• Oversees timely resolution of and response to member and provider issues in conjunction with Quality Management, Pharmacy, Utilization Management, and other HPP departments/sub-contractors.
• Review and interpret Health Care Management case notes, medical records and pharmacy profiles and draft comprehensive case summaries to forward to external and internal physicians, pharmacists, nurses and other Plan staff for reviews and to present to committee members for hearings.
• Draft well-written acknowledgment, review notification, and decision letters timely in response to member complaints and grievances.
• Facilitates written and verbal communication of and scheduling/preparation for 1st and 2nd Level member Complaint committees and Grievance hearings.
• Prepares and presents Complaints and Grievances to the Complaint and Grievance Committees in accordance with the Health Choices Agreement including coordination with a legal representative when an attorney is representing a member.
• Prepares cases for External reviews to the Department of Health or to a Certified Review Entity and ensure they are submitted timely with all the relevant documentation.
• Maintains corporate policies and procedures and other formal documents pertinent to the Complaint and Grievance function/option in conjunction with either the Department of Health and or Pennsylvania Insurance Department.
• Performs special projects as assigned by management.
• Perform other duties as assigned.

Benefits

• Jefferson offers a comprehensive package of benefits for full-time and part-time colleagues, including medical (including prescription), supplemental insurance, dental, vision, life and AD&D insurance, short- and long-term disability, flexible spending accounts, retirement plans, tuition assistance, as well as voluntary benefits, which provide colleagues with access to group rates on insurance and discounts.
• Colleagues have access to tuition discounts at Thomas Jefferson University after one year of full time service or two years of part time service.
• All colleagues, including those who work less than part-time (including per diem colleagues, adjunct faculty, and Jeff Temps), have access to medical (including prescription) insurance.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level