Appeals and Compliance Specialist

5 days ago


Southfield, Michigan, United States Area Agency on Aging 1-B Full time
Job Title: Appeals and Compliance Specialist

The Area Agency on Aging 1-B is seeking a highly skilled Appeals and Compliance Specialist to join our team. As a key member of our organization, you will be responsible for ensuring compliance with contract, regulatory, and accreditation requirements related to Medicaid managed care services.

Key Responsibilities:
  • Conduct comprehensive reviews of appeals and investigations to ensure compliance with contractual, regulatory, and accreditation guidelines.
  • Communicate with participants, providers, and regulatory agencies to gather information and provide disposition of appeals.
  • Collaborate with the Compliance Officer and other team members to ensure accurate and timely completion of investigations and appeals.
  • Utilize established clinical criteria, Medicaid contract requirements, and other resources to develop sound and well-supported appeal and investigation correspondence.
  • Stay up-to-date with current knowledge of internal policies, processes, accreditation standards, and existing laws.
Requirements:
  • Minimum Associate's or Nursing Degree with current State of MI nursing license required for RN candidates.
  • 2-4+ years of experience in an administrative clinical setting, including 1-2 years of Medicaid managed care appeals process and Health/Human Services experience for candidates with experience.
  • Excellent interpersonal, communication, organizational, training, and investigative skills.
  • Ability to conduct clinical case/documentation reviews, present findings, and appeals recommendations.
  • Effective time management skills, including the ability to meet deadlines.
Benefits:
  • Choice of 3 excellent next to zero cost Medical Plans including Dental and Vision.
  • 401K - Agency contributes 50% match up to first 6% contribution.
  • Fitness and Wellness programs.
  • Excellent PTO package- Minimum 4 weeks accrual for the first year.
  • Get 10 paid holidays and 3 floating.
  • Mileage reimbursed for business travel.


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