Temporary Health Plan Appeals Specialist - Hybrid

Temporary Health Plan Appeals Specialist - Hybrid### Temporary Health Plan Appeals Specialist - HybridApply: Portland, ME: Full time: Posted Today: REQ-2026-391Join Martin's Point Health Care - an innovative, not-for-profit health care organization offering care and coverage to the people of Maine and beyond. As a joined force of \"people caring for people,\" Martin's Point employees are on a mission to transform our health care system while creating a healthier community. Martin's Point employees enjoy an organizational culture of trust and respect, where our values - taking care of ourselves and others, continuous learning, helping each other, and having fun - are brought to life every day. Join us and find out for yourself why Martin's Point has been certified as a \"Great Place to Work\" since 2015.## Position SummaryMedicare and US Family Health Plan (USFHP) Appeal Specialists are responsible for processing of all member appeals, non-participating provider pre- and post-service appeals, and participating provider pre-service appeals. The Specialists collaborates with Care Managers, Medical Directors and Compliance partners, as well as other internal and external partners to ensure a comprehensive appeals management process.## Job Description**PRIMARY DUTIES AND RESPONSIBILITIES*** Demonstrates advanced knowledge and expertise in processing both Generations Advantage and US Family Health plan appeals and grievances. This includes expertise in case classification, including organization and coverage determinations for both lines of business.* Demonstrates advanced knowledge of claims processing and health plan benefits necessary for the Appeals Specialist to exercise decision-making authority to reprocess claims in accordance and alignment with regulatory and internal policies.* Independently and with judgement, conducts multi-faceted, complex investigations through claims review, provider credentialing, authorization processing, timeliness evaluations, and plan benefits design.* Maintains and manages multiple work queues in alignment with regulatory timeframes and internal performance policies. These include inbound mail, fax, voicemail, internal communication platforms and an electronic Appeals management system.* Responsible for all written and verbal communication with external downstream-entities, provider offices, customers and internal business partners appeals related asks.* Drafts and issues regulatorily compliant communications requiring advanced knowledge necessary to analyze, interpret and respond promptly to the requests based on facts and circumstances of the case.* Responsible for call case file creation, management and oversight of case submission to required review entities (i.e. QIO, DHA, etc.).* Serves at the key contact for these entities related to each case submitted. This work includes the monitoring and tracking to case completion.* Prepares files and participates in both internal and external auditing activities. These reviews may include activities like the Defense Health Agency (DHA) Annual review, NCQA certification audit, CMS Data Validation audits or CMS Full Program audits.* Prepares files for second level appeals through DHA or ALJ.* Cross departmental support for training and workflows associated with complex appeals processing, including health plan appeals training, appeals trend reporting and general appeals oversight.* Skillfully conducts provider and beneficiary outreach for the purposes of investigation and resolution of appeals, including outreach to provider billing offices and facilities.* Independently reviews/updates policies, procedures, forms, workflow and letter templates on semi-annual basis.* Evaluates and implements process improvements and operational efficiencies associated with case classification and appeals processing.* Participates and conducts internal system upgrade testing to include support annual benefit development and implementation of regulatory changes when they occur as it relates to the appeals process.* Serves as daily resource for staff and partner department questions and appeals related escalations.* Serves as the subject matter expert for TRICARE and US Family Health Plan manuals related to appeals, as well as CMS Part C and Part G Organization Determinations and Grievances guidance.* Independently partners with Medical Directors and other clinical support staff on appeals requiring clinical decision making determinations.* Maintains responsibility to maintain timeframe requirements on decision making and communication processes after-hours and during holidays to maintain all regulatory and statutorily required timeframes.Employees are expected to work consistently to demonstrate the mission, vision, and core values of the organization.**POSITION QUALIFICATIONS****Education:*** Bachelor’s Degree or equivalent experience and education**Experience:*** 5+ years’ experience in managed care plan preferred**Knowledge:*** Knowledge of Medicare Advantage and/or TRICARE appeals processes and regulations strongly preferred**Skills:*** Excellent written and verbal communication skills* Effective time management skills and organization skills* Strong interpersonal skills and the ability to collaborate with internal and external clients* Excellent customer service skills* Strong organizational skills and able to meet deadlines (ability to prioritize and multi-task while maintaining focus on objectives)**Abilities:*** Demonstrates an understanding of and alignment with Martin's Point Values* Must have a track record of producing high-quality work; highly accurate, demonstrates attention to detail, and reflects well on the organization* Strong analytical, problem-solving and mathematical skills* Proficiency in Microsoft Office applications (Word, Excel, PowerPoint)* Self-driven and self-motivated; ability to function independently with sound decision making* Ability to take appropriate initiative while soliciting input/advice appropriately* Ability to handle confidential and sensitive information in a discreet and professional manner* Ability to handle high volume of work while maintaining accuracy and timeliness requirementsPay Range:$65,725.40 - $81,190.20To promote pay equity, Martin’s Point Healthcare has established defined salary ranges for each role. Compensation is established within the posted range based on a variety of factors, including relevant years of experience, current market conditions, internal equity, and budget considerations.The pay range reflects the potential compensation for this role based on a full-time position. Employees may also be eligible for additional compensation, such as incentive or commission-based programs, where applicable and subject to the terms of the applicable plan.Final compensation is determined at the conclusion of the interview process. We encourage you to apply even if your desired compensation falls outside of the listed range. ## *This position is not eligible for immigration sponsorship.* ## *We are an equal opportunity/affirmative action employer.* ## *Martin's Point complies with federal and state disability laws and makes reasonable accommodations for applicants and employees with disabilities. If a reasonable accommodation is needed to participate in the job application or interview process, to perform essential job functions, and/or to receive other benefits and privileges of employment, please contact* View email address on click.appcast.io you have a question about careers at Martin’s Point Health Care? Contact us at: View email address on click.appcast.io #J-18808-Ljbffr Martins Point