Customer Service Appeals Specialist

3 weeks ago

Detroit, Michigan, United States Detroit Wayne Mental Health Authority Full time
Job Description

As a key member of the Detroit Wayne Integrated Health Network team, the Customer Service Appeals Specialist plays a vital role in ensuring that the appeals process is carried out in accordance with local, state, and federal regulations. This position requires strong analytical and communication skills, as well as the ability to work collaboratively with various stakeholders to resolve complex issues.

Key Responsibilities:

  • Administer the appeals process and procedures in accordance with all relevant regulations and policies.
  • Monitor the appeals process to ensure compliance with established policies and procedures.
  • Collaborate with dispute resolution and appeals units to address issues in accordance with mandated policies and procedures.
  • Enforce the Network's policies on Local Appeals, Local Dispute Resolution, State Fair Hearing, and Mediation processes.
  • Maintain a database to track and monitor appeals and final dispositions.
  • Review and analyze appeal logs and data to identify trends and patterns.
  • Provide weekly and monthly reports on appeals activity to internal and external entities.
  • Provide technical assistance to Network staff and contractors on the appeals process and applicable dispute resolution protocols.
  • Provide Due Process information, referral, linkage, and follow-through for telephone and walk-in inquiries.
  • Assist in the preparation of the State Administrative Hearing/Medicaid Fair Hearing process.
  • Develop, implement, and conduct ongoing appeals training modules.
  • Develop and maintain standardized appeals educational and informational materials.
  • Facilitate periodic meetings with network provider appeals contacts to address Network updates and issues applicable to appeals activities.
  • Develop and enact the Network and contractor Appeals Compliance Audit Review tool(s) in accordance with Federal, State, and Local requirements.
  • Assist in monitoring and training the Network on the disenrollment process.
  • Oversee the Explanation of Benefits process for Medicaid and MI Health Link members.
  • Perform related duties as assigned.

Requirements:

  • Bachelor's degree from a recognized college or university.
  • Four (4) years of full-time paid professional experience in the field of complex cross-functional appeal/dispute resolution or consumer relations.
  • Experience working with due process procedures (i.e., complaints, appeals, and/or grievances).

Working Conditions:

This position requires the ability to work in an office setting and drive to different sites throughout Wayne County and the State of Michigan. The position can work remotely with supervisory approval.

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