Job Details

The Medicare Appeals Specialist is responsible for independently coordinating Part C & Part D Expedited, Pre-Service and Standard Appeals and Grievances from receipt to resolution. The Specialist must have a broad knowledge of products and benefits as well as have an understanding of 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
• Must have a thorough understanding of Health Plan operations and business unit processes, work flows and system requirements, including but not limited to, authorizations, billing, claims and regulatory compliance and plan benefits. Work closely with Medical Directors and Claims staff to resolve appeals timely and accurately.

• Ensures the timely and accurate documentation, review, routing and tracking of member issues in compliance with regulations established by external regulating bodies and applicable state and federal laws.
• Handles multiple issues and prioritizes appropriately with the ability to organize work to meet deadlines.
• Conducts research by speaking with members and providers, reviewing member’s records and benefit plan and obtaining responses from various business areas.
• Demonstrates ability to process complex information and deliver the information both verbally and written, in a professional, clear, concise and articulate manner.
• Requires excellent interpersonal skills in order to communicate and work with multiple constituents and be able to recognize sensitive issues and when to escalate to Management.
• Must provide formal well-written communication to members and providers in conjunction with the complaint, grievance and appeal process and independently handle high volume of cases.
• Prepares case files for Independent Review Entities that are well organized, contain relevant documentation and are processed within the required timeframes.
• Maintains corporate policies and procedures and other formal documents pertinent to the complaint, grievance and appeal functions and collect mandatory data for CMS Universes.
• Be available to participate in the on-call process during weekends and holidays on a rotation basis.
• Other duties as assigned.

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, autonomous, productive and takes initiative.
• Ability to handle multiple responsibilities and changing priorities
• Advanced knowledge of Microsoft Office (Excel and Word. CCMS, MACESS, and relational databases

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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