Job Details

The Appeals Specialist is responsible for independently coordinating Medicaid & CHIP Standard and Expedited Complaints and Grievances from receipt to resolution. The Appeals Specialist must have a broad knowledge of products and benefits as well as understand regulatory requirements and timeframes.

Job Description

Essential Functions:

Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• Able to work in a constant state of alertness and safe manner.
• Keeps current with all rules, regulations, policies, and procedures relevant to the Complaints, Grievances, and Appeals Unit.
• Must have a thorough understanding of Health Plan operations and business unit processes, workflows and system requirements, including but not limited to, authorizations, billing, regulatory compliance, and plan benefits. Work closely with Medical Directors and other Health Plan staff to resolve Grievances (i.e.) appeals timely and accurately.
• Manages case load, multiple systems, and plans appropriate allocation of resources to provide quality assessment of assigned Complaints and Grievances.
• Handles multiple issues and prioritizes appropriately with the ability to organize work to meet deadlines.
• Develops and maintains collaborative relationships with internal and external customers.
• Performs outreach calls to members, head of household, and authorized representatives.
• Ensures the timely and accurate review, routing, and tracking of member Complaint and Grievance issues in compliance with Medicaid and CHIP requirements.
• Identifies and analyzes various member issues/concerns and ensures well documented resolution(s) of the same are entered real-time.
• Interpret member benefit limit exceptions and denial information in order to clearly communicate and manage expectations.
• Outreaches to provider offices to obtain responses to member complaints involving primary care physicians, specialists, hospitals, ancillary services/durable medical equipment, delegated vendors, and their staff.
• Oversees timely resolution of and response to member and provider issues in conjunction with Quality Management, Pharmacy, Utilization Management, and other HPP departments/sub-contractors.
• Review and interpret Health Care Management case notes, medical records and pharmacy profiles and draft comprehensive case summaries to forward to external and internal physicians, pharmacists, nurses and other Plan staff for reviews and to present to committee members for hearings.
• Draft well-written acknowledgment, review notification, and decision letters timely in response to member complaints and grievances.
• Facilitates written and verbal communication of and scheduling/preparation for 1st and 2nd Level member Complaint committees and Grievance hearings.
• Prepares and presents Complaints and Grievances to the Complaint and Grievance Committees in accordance with the Health Choices Agreement including coordination with a legal representative when an attorney is representing a member.
• Prepares cases for External reviews to the Department of Health or to a Certified Review Entity and ensure they are submitted timely with all the relevant documentation.
• Maintains corporate policies and procedures and other formal documents pertinent to the Complaint and Grievance function/option in conjunction with either the Department of Health and or Pennsylvania Insurance Department.
• Performs special projects as assigned by management.
• Perform other duties as assigned.

Supervisory Responsibility:

N/A.

Work Environment:

This job operates in a professional office environment.  This role routinely uses standard office and computer equipment.

Physical Demands

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of the job. 

While performing the duties of this job, the employee is regularly required to talk and hear.  This position may occasionally require standing, walking, bending, kneeling, stooping or crouching.  The employee must frequently lift and or move items over 20 pounds.  Specific vision abilities required by this job include close vision, distance vision, color vision, peripheral vision, depth perception and ability to adjust focus.

Employee may be required to sit for prolonged periods of time.

Required Education and Experience:

• Bachelor’s degree or paralegal preferred
• 3-5 years of experience in processing Medicaid and/or CHIP Complaints and Grievances or a concentration in compliance, legal, or quality management

• Strong communication (written/oral) and organization skills with a great level of attention to detail.
• Ability to interpret medical terminology and regulations to apply them without direct supervision.
• Exceptional customer service and presentation skills.
• Exceptional productivity, autonomy, and initiative.
• Ability to handle multiple responsibilities and changing priorities.
• Advanced knowledge of Microsoft Office (Excel and Word), CCMS, MACESS, and relational databases.

Medicare Advantage Compliance Statement:  Compliance with all applicable rules, regulations and laws is a condition of employment.  Employees must read and sign, both the Business Code of Conduct and the Personal Standard Code of Conduct, and are expected to perform their duties ethically and honestly.

Access To Protected Health Information:  LA

Other Duties

Please note this job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for their job. Duties, responsibilities, and activities may change at any time with or without notice.

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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