Appeals Specialist

1 month ago

Portland, United States Martins 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

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