Current jobs related to Appeals Specialist - Portland - Martin's Point Health Care

  • Fruit Arrangement Specialist

    3 weeks ago

    Portland, Oregon, United States Edible Arrangements Full time

    Fruit Arrangement SpecialistWe are seeking a skilled Fruit Arrangement Specialist to join our team at Edible Arrangements of Portland. This role combines customer service with the creative task of designing and preparing our signature fruit arrangements.Key Responsibilities:Provide Exceptional Customer ServiceDesign and Prepare Fruit ArrangementsCollaborate...

  • Proposal Development Specialist

    2 weeks ago

    Portland, Maine, United States MOREgroup Full time

    Job OverviewAt MOREgroup, we are seeking a highly skilled Pursuit Specialist to join our team. As a key member of our business development team, you will play a critical role in supporting the growth and success of our company.Key Responsibilities:Develop and manage high-quality proposals that showcase our company's expertise and value...

  • Maintenance Specialist

    3 weeks ago

    Portland, Oregon, United States Guardian Management Full time

    Full-Time Maintenance Specialist at Guardian ManagementWe are seeking a highly skilled and organized Full-Time Maintenance Specialist to join our team at Guardian Management, a leading property management company in the Northwest. As a Maintenance Specialist, you will be responsible for ensuring property maintenance, safety, and excellent curb appeal.Key...

  • Property Maintenance Specialist

    4 weeks ago

    Portland, Oregon, United States Guardian Management Full time

    Full-Time Property Maintenance Specialist at Guardian ManagementWe are seeking a proactive and detail-oriented Full-Time Property Maintenance Specialist to become a valuable member of our team at Guardian Management. This role is essential in maintaining the functionality and aesthetic appeal of our apartment community.Key Responsibilities:Ensure the upkeep...

  • Bakery Specialist

    2 weeks ago

    Portland, Michigan, United States Tom's Food Center Full time

    About Tom's Food CenterWe're seeking a skilled Bakery Specialist to join our team at Tom's Food Center. As a key member of our food production team, you will be responsible for ensuring the highest quality bakery products are prepared and presented to our customers.Key Responsibilities:Bakery Operations: Manage the production schedule to ensure timely and...

  • Customer Engagement Specialist

    4 weeks ago

    Portland, Oregon, United States Dark Horse Comics Full time

    The Customer Engagement Specialist plays a vital role in delivering outstanding service and meeting sales objectives by assisting patrons with inquiries regarding the products and services available at Dark Horse Comics. Our associates are expected to maintain a professional demeanor both in-store and online, embodying our principles of inclusivity, respect,...

  • Healthcare Billing Specialist

    4 weeks ago

    Portland, Oregon, United States Emerald Staffing Full time

    Job OverviewAbout Emerald StaffingEmerald Staffing is a leading provider in the healthcare staffing industry, seeking a dedicated Healthcare Billing Specialist to enhance our administrative operations. This role is ideal for those with a background in medical billing or those eager to start their career in this field.Position SummaryAs a Healthcare Billing...

  • Digital Marketing Specialist

    3 weeks ago

    Portland, Oregon, United States AireSpring Full time

    B2B Digital Marketing SpecialistAireSpring is seeking a highly skilled Digital Marketing Specialist to drive our digital marketing strategies. This role requires a creative and detail-oriented individual with a passion for B2B marketing.Key Responsibilities:Assist in planning and executing digital B2B marketing campaigns to drive business growth and...

  • Vehicle Care Specialist

    3 weeks ago

    Portland, Oregon, United States Kaady Car Wash Full time

    Position OverviewKaady Car Wash is seeking enthusiastic and self-driven individuals who take pride in assisting customers with the upkeep and aesthetic appeal of their vehicles. Our commitment to providing a safe and efficient service is paramount.With over 40 years in the industry, Kaady values internal growth, often promoting from within. This creates...

  • Merchandising Specialist

    1 week ago

    Portland, Maine, United States Jacent Strategic Merchandising Full time

    About Jacent Strategic MerchandisingJacent Strategic Merchandising is a leading cross-merchandising impulse product company in North America, offering innovative solutions to simplify the retail industry.Job SummaryWe are seeking a skilled Merchandising Specialist to join our team. As a Merchandising Specialist, you will be responsible for cultivating...

  • Housekeeping Specialist

    4 weeks ago

    Portland, Oregon, United States Peachtree Hospitality Management Full time

    Position Overview: We are seeking a meticulous and dedicated Housekeeping Specialist to ensure the highest standards of cleanliness and order within our facilities at Peachtree Hospitality Management. The successful candidate will play a vital role in creating a welcoming environment for our guests.Key Responsibilities:Thoroughly clean and disinfect guest...

  • Vehicle Care Specialist

    4 weeks ago

    Portland, Oregon, United States Kaady Car Wash Full time

    Position OverviewKaady Car Wash is seeking enthusiastic and self-driven individuals who take pride in assisting customers with the upkeep and aesthetic appeal of their vehicles. Our mission is to provide the safest and most efficient service possible.With over 40 years in the industry, we have a strong tradition of promoting from within. We offer significant...

  • Bakery Production Specialist

    2 weeks ago

    Portland, Michigan, United States Tom's Food Center Full time

    About Tom's Food CenterWe're a leading food retailer seeking a skilled Bakery Production Specialist to join our team. As a key member of our bakery department, you will be responsible for producing high-quality baked goods that meet our customers' expectations.Key Responsibilities:Baking and Frying Duties: You will be responsible for baking and frying a...

  • Client Relations and Sales Specialist

    4 weeks ago

    Portland, Maine, United States Relax Me Inc dba Massage Envy South Portland Full time

    Job OverviewMassage Envy Client Relations & Sales Specialist - Full and Part-time opportunities availableAre you interested in being part of a dedicated and efficient team focused on enhancing the overall wellness and aesthetic appeal of our clients? We achieve these goals by delivering exceptional therapeutic massage and skincare services at highly...

  • Facilities Maintenance Specialist

    4 weeks ago

    Portland, Oregon, United States C&R Management Group LLC Full time

    Job OverviewPosition: Facilities Maintenance SpecialistC&R Management Group LLC is seeking a dedicated Facilities Maintenance Specialist to ensure the operational integrity and aesthetic appeal of our residential and commercial properties. This role involves performing routine maintenance tasks, managing repairs, and maintaining the overall cleanliness of...

  • Paralegal Specialist

    3 weeks ago

    Portland, Oregon, United States LHH Recruitment Solutions Full time

    Job SummaryLHH Recruitment Solutions is seeking a skilled Paralegal Specialist to provide comprehensive legal support to attorneys in a fast-paced environment. The ideal candidate will have 3+ years of experience and possess excellent communication, organizational, and time-management skills.Key ResponsibilitiesAssist attorneys with case preparation,...

  • Paralegal Specialist

    3 weeks ago

    Portland, Oregon, United States LHH Recruitment Solutions Full time

    Job OpportunityLHH Recruitment Solutions is seeking a skilled Paralegal Specialist to provide comprehensive legal support to our attorneys. The ideal candidate will have 3+ years of experience and be detail-oriented, organized, and capable of managing multiple priorities in a fast-paced environment.Key ResponsibilitiesAssist attorneys with case preparation,...

  • Bakery Production Specialist

    2 weeks ago

    Portland, Michigan, United States Tom's Food Center Full time

    We are seeking a skilled Bakery Production Specialist to join our team at Tom's Food Center. As a key member of our bakery team, you will be responsible for producing high-quality baked goods and ensuring a smooth production process.Key Responsibilities:Baking and Production: Prepare and bake a variety of breads, pastries, and other baked goods according to...

  • Automotive Appearance Specialist

    4 weeks ago

    Portland, Oregon, United States Lithia Motors Full time

    Company: Lithia Motors Join Our Team as an Automotive Appearance Specialist If you are passionate about delivering exceptional service and take pride in your work, we invite you to consider a position with us. Our mission is to ensure that every customer leaves with a sense of satisfaction and joy. Position Overview: Schedule: Full-Time Compensation:...

  • Wellness Reception Specialist

    4 weeks ago

    Portland, Oregon, United States CASCADA PDX Full time

    Wellness Reception Specialist Job OverviewCascada PDX is seeking a dedicated and service-oriented Wellness Reception Specialist to be the first point of contact for our esteemed members and guests. This role is pivotal in creating a welcoming atmosphere and ensuring seamless operations at our wellness center.Key Responsibilities:Greet and Engage: Warmly...

Appeals Specialist

4 months ago

Portland, United States Martin's Point Health Care Full time

Join Martin's Point Health Care - an innovative, not-for-profit health care organization offering care and coverage to the people of Maine and beyond. As a joined force of "people caring for people," Martin's Point employees are on a mission to transform our health care system while creating a healthier community. Martin's Point employees enjoy an organizational culture of trust and respect, where our values - taking care of ourselves and others, continuous learning, helping each other, and having fun - are brought to life every day. Join us and find out for yourself why Martin's Point has been certified as a "Great Place to Work" since 2015.

Position Summary

Job Description

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.

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.

Do you have a question about careers at Martin's Point Health Care? Contact us at: jobinquiries@martinspoint.org