UM Appeals Specialist (Hybrid)

Full Time Administrative Supp Gastonia, NC, US Competitive Compensation & Benefits Package Annual incentive bonus plan Medical, dental, and vision insurance with low deductible/low cost health plan Generous vacation and sick time accrual 12 paid holidays State Retirement (pension plan) 401(k) Plan with employer match Company paid life and disability insurance Wellness Programs Public Service Loan Forgiveness Qualifying Employer Office Location: Available for the Gastonia, NC location. Hybrid (must work in the office 2 days per week). Projected Hiring Range Depending on Experience Closing Date Open Until Filled Primary Purpose of Position This position is responsible for implementing and supporting the LME/MCO Medicaid and State appeals process. Role and Responsibilities Implementation of MCO Medicaid and non-Medicaid Appeals Processes: Preparing, proofreading and verifying the accuracy of the LME/MCO notification letters to members/recipients/legal guardian/legal representatives and providers of reductions, suspensions, terminations or denials of services Assisting members/recipients, legal guardians and/or legal representatives in completing appeal requests for the agency Following federal, state and organizational policies Receive, track and follow individual authorization appeals from initiation to completion Work collaboratively with members/recipients/ legal guardian/legal representatives, providers, stakeholders, agency staff and others as necessary to ensure due process of authorization appeals Monitor the assignment of the local reconsideration review process for each appeal Timely documentation of all contacts with member/recipient/guardian, reviewer and providers; and establish and maintain the denial and appeals records Additional duties as needed to support and/or provide oversight of the appeals process in clinical operations and other organizational departments as deemed applicable Educate: Provide education, support and information to member/recipient, legal guardians, legal representatives and providers concerning and during the appeals process Answer questions about appeals process and assist member/recipient, legal guardians, and legal representatives in completing appeals forms (Medicaid & Non-Medicaid) Liaison: Serves as a staff liaison for all member/recipient, legal guardians, legal representative, providers, community stakeholders and the agency staff regarding all adverse events Responds to questions regarding authorization appeals in a timely manner Misc: Uses tact and diplomacy in communication with members/recipients, legal guardians, legal representatives, providers and others while working through the appeals process Effectively works with others to ensure timeliness of appeals process Appropriately responds to or directs questions/concerns and promotes a positive work environment. Participates in a telephone workgroup rotation to address calls received in the Appeals department. Other duties as assigned by Supervisor. Knowledge, Skills and Abilities Knowledge of Federal and State regulations on behavioral healthcare denials and appeals processes National Accreditation knowledge specific to organization Knowledge of medical records practices and recordkeeping practices, including electronic records and imaging/scanning processes Knowledge in preparation for legal proceedings including mediation, administrative law courts and other legal processes Knowledge of agency policies and procedures that pertain to duties Knowledge of DMA and Division contracts specific to organization Knowledge of service definitions and DMA clinical policy Proficiency in Microsoft Office products (Word, Excel, Outlook, PowerPoint, etc.) Ability to organize multiple tasks and priorities and to effectively manage numerous details Ability to effectively and accurately manage projects from start to finish Ability to understand and adhere to amendments and priorities at the State, Federal, Accreditation or contract level Education and Experience Required Bachelor’s Degree and two (2) years of Human Services/healthcare experience or a comprehensive combination of education and experience may be accepted. Education and Experience Preferred A Qualified Professional (QP) with IDD/BH, Pharmacy and/or Physical Health/Medical experience is preferred. Licensure/Certification Requirements None Required #J-18808-Ljbffr