Member Appeals Representative

2 weeks ago

Schenectady, New York, United States MVP Health Care Full time

Medicare Appeals Specialist
Become an integral member of MVP Health Care, a well-established organization with a legacy of over 35 years in the healthcare sector. Our dedicated team of professionals is committed to delivering exceptional service across New York and Vermont.

At MVP, we pride ourselves on our diverse workforce, which includes individuals with a range of skills from technology to analytics, all working together to improve the health insurance experience. If you are looking for a meaningful career in a mission-driven company where you can make a difference, consider joining us.

Status:
Full-time, Non-Exempt

Under the direction of the Appeals Manager:

Engage in comprehensive investigations and resolutions of member appeals and complaints in a professional and timely manner, ensuring compliance with departmental protocols and CMS guidelines.

Recognize trends in appeals and identify opportunities for service enhancement.


Key Responsibilities:

Conduct thorough investigations of appeals by collecting essential information from members, providers, and internal resources to meet response timelines. Generate timely resolution communications and serve as the primary contact for member inquiries. Track cases for patterns, propose improvement strategies, manage member correspondence, and provide ongoing education regarding MVP policies. Stay updated on Medicare regulations and guidelines to ensure accurate processing of appeals.

Maintain detailed documentation of appeal cases, keep correspondence records, and communicate effectively with all relevant parties. Exhibit strong conflict resolution skills, update databases, and adapt to changes in operations. Collaborate with various departments and external partners to efficiently resolve appeal issues.

Qualifications:
Minimum Education:
2-4 year degree or equivalent experience

Minimum Experience:

Prior experience in Medicare Appeals for Part C and D, along with a minimum of one year in the Medicare health insurance sector.

Required Skills:
  • Extensive experience in Medicare Appeals
  • Thorough understanding of Medicare Managed Care Part C and Part D, including benefits, regulations, policies, and payment processes
  • Exceptional verbal and written communication, organizational, analytical, and interpersonal skills
  • Strong customer service focus and problem-solving abilities
  • Capability to manage confidential information with care
  • Proficiency in Microsoft Office applications, particularly Access and Outlook
  • Experience with Independent Review Entities (IREs) and Administrative Law Judges (ALJs)
  • Familiarity with medical management systems such as Facets, Macess, and CareRadius

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