Job Details

The Senior Appeals Specialist, in collaboration with various internal HPP departments and external entities, ensures the timely closure of member quality of care complaints and grievance issues related to pharmacy, radiology, behavioral health and inpatient and outpatient services. In pursuit of complaint, grievance ,and appeal resolution, reviews documentation and interprets data obtained from clinical records to apply appropriate clinical criteria and policies in line with regulatory and accreditation requirements for member issues.

Job Description

• Keeps current with all rules, regulations, policies and procedures relevant to the Complaints, Grievances and Appeals Unit
• Review and interpret Health Care Management case notes, medical records and pharmacy profiles and draft comprehensive case summaries to forward to outside Physician Consultants for 1st level reviews and to present to committee members.
• Ensures the timely and accurate review, routing and tracking of member issues in compliance with Medicaid and CHIP requirements
• Independently process assigned cases from receipt to resolution, and accurately document the decision in a resolution letter to the member
• Serves as a back-up as needed when other staff, including CG&A Management are out of the office and cases require to be worked on, assigned or issues need to be addressed.
• As needed, assists Team Leader in training staff and meeting with other departments to provide an overview of CG&A.
• Develops and maintains collaborative relationships with internal and external customers, including physicians, attorneys and Health Partners Plans’ management staff
• Handles multiple issues and prioritize appropriately with the ability to organize work to meet deadlines
• In response to formal member inquiries, draft well-written resolution letters detailing the issue, the investigation and Health Partners Plans’ decision.
• Facilitates communication of and scheduling/preparation for 1st level grievance hearings and 1st and 2nd level complaint reviews and provides formal written communication to member at closure of hearings and reviews.
• Prepares cases for external reviews to the Department of Health or to a Certified Review Entity and ensure they are submitted timely
• Conducts hearings before a panel of arbitrators, administrative judges and/or physicians
• Maintains corporate policies and procedures and other formal documents pertinent to the complaint, grievance and appeal function
• Performs other duties as assigned

Work Environment:

This job operates in a remote setting. 

HPP allows employees to work remotely based on its determination that a remote work arrangement is appropriate based on HPP’s business needs and the employee’s ability to perform the job remotely in an effective manner.  Should those business needs change, HPP reserves the right to change the remote working arrangement at any time, in accordance with HPP’s Flexible Remote-Working Policy. HPP will provide a minimum notice of 60 days of any change in the remote working arrangement,

Physical Demands

While performing the duties of this job, the employee is regularly required to talk and hear.

Travel

0% of work week, unless otherwise required for business needs.

Work Location

This position is available to work from home; in accordance with our Flexible Remote-Working Policy, who you will be required to acknowledge and sign upon hire.

Key Job Requirements:

Education:                             High School Diploma/GED or Bachelor’s Degree preferred.

                                                Significant writing experience and a minimum 4 years’ experience in managed care.

Skills/Abilities:                       Strong communication (written/oral), and organization skills with great level of attention to detail

                                                Ability to interpret medical terminology, regulations/statutes and apply them without direct supervision

                                                Exceptional presentation skills

                                                Knowledge of Microsoft Office, Health Rules Payor, HRCM, Salesforce, and relational databases

Access to Protected Health Information:  LA

Work Shift

Workday Day (United States of America)

Worker Sub Type

Regular

Employee Entity

Health Partners Plans, Inc.

Primary Location Address

1101 Market, Philadelphia, Pennsylvania, United States of America

Nationally ranked, Jefferson, which is principally located in the greater Philadelphia region, Lehigh Valley and Northeastern Pennsylvania and southern New Jersey, is reimagining health care and higher education to create unparalleled value. Jefferson is more than 65,000 people strong, dedicated to providing the highest-quality, compassionate clinical care for patients; making our communities healthier and stronger; preparing tomorrow's professional leaders for 21st-century careers; and creating new knowledge through basic/programmatic, clinical and applied research. Thomas Jefferson University, home of Sidney Kimmel Medical College, Jefferson College of Nursing, and the Kanbar College of Design, Engineering and Commerce, dates back to 1824 and today comprises 10 colleges and three schools offering 200+ undergraduate and graduate programs to more than 8,300 students. Jefferson Health, nationally ranked as one of the top 15 not-for-profit health care systems in the country and the largest provider in the Philadelphia and Lehigh Valley areas, serves patients through millions of encounters each year at 32 hospitals campuses and more than 700 outpatient and urgent care locations throughout the region. Jefferson Health Plans is a not-for-profit managed health care organization providing a broad range of health coverage options in Pennsylvania and New Jersey for more than 35 years.    

Jefferson is committed to providing equal educa­tional and employment opportunities for all persons without regard to age, race, color, religion, creed, sexual orientation, gender, gender identity, marital status, pregnancy, national origin, ancestry, citizenship, military status, veteran status, handicap or disability or any other protected group or status. 

Benefits

Jefferson offers a comprehensive package of benefits for full-time and part-time colleagues, including medical (including prescription), supplemental insurance, dental, vision, life and AD&D insurance, short- and long-term disability, flexible spending accounts, retirement plans, tuition assistance, as well as voluntary benefits, which provide colleagues with access to group rates on insurance and discounts. Colleagues have access to tuition discounts at Thomas Jefferson University after one year of full time service or two years of part time service. All colleagues, including those who work less than part-time (including per diem colleagues, adjunct faculty, and Jeff Temps), have access to medical (including prescription) insurance.

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