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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:
For Medicare Focused Specialist:
Researches, processes and resolves Part C reconsiderations with 100% compliance
Prepares for, and participates in CMS, NCQA, and Health Plan audits
Serves as the subject matter expert for Part C appeals Medicare Managed Care Manuals
For USFHP Focused Specialist:
Researches, processes and resolves all appeals in accordance with Tricare and NCQA guidelines.
Serves as the subject matter expert for TRICARE and US Family Health Plan manuals and benefits pertaining to Member Appeals
Prepares appeals documentation within contractual and regulatory requirements
Independently manages multiple work queues, streams of correspondence from providers and members
Determines the nature of appeals and correspondences and ensures adherence to Standard Operating Procedures (SOP) to determine next steps
Evaluates medical claims and coverage policy documentation to determine validity of the appeal
Data entry of appeals to track case details, correspondences, and monitor timeliness of resolution
Maintains case files in organized and secure manner, both electronically and written
Conducts telephone work with members, providers and third-party administrators
Prepares case files on clinical member and provider appeals for review by clinical team members
Prepares and sends appeal case files for all appeal levels in accordance with regulatory requirements
Responsible for ensuring and monitoring effectuation of all decisions as a result of the appeal process
Works with leadership to develop appropriate policies and procedures
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
Maintains confidentiality while providing quality customer service to internal and external customers
Cross-trains to perform either Medicare or USFHP Appeals Specialist functions as needed
Education/Experience:
Bachelor’s Degree or equivalent experience and education
3+ 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 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