Appeals Coordinator

State of Maryland•Baltimore City, MD

3d•Onsite

About The Position

The main purpose of this position is to interpret and apply Federal and State regulations and policies to all provider and recipient appeals within the Medicaid Program. In addition, this position assists in the execution of applicable Federal and State exclusion and termination regulations and policies to make programmatic updates when acting to terminate, suspend and sanction providers. The position coordinates and acts as a liaison with other state Medicaid programs as well as federal entities regarding exchanging termination and exclusion data. These functions are required by CMS so that we provide a nationwide alert to all states and effectively prohibit a provider from receiving future reimbursement and protect the health and safety of Medicaid/Medicare participants. This position prepares reports for Medical Care Program staff regarding appeals and excluded providers. This position coordinates all appeals and ensures Program staff adheres to procedural requirements of the appeals process. This position requires detailed program knowledge of the functions of the OLTSS Medical Care Programs as well as knowledge of databases including Long Term Supports Services (LTSS), In Home Supports and Assurances (ISAS), Maryland Medicaid Information System (MMIS), Medicaid Appeals Database and Medicaid Provider Database.

Requirements

Seven years of administrative or professional experience developing or applying policies and regulations in medical assistance, health insurance, federal or State entitlement programs.
Possession of a Bachelor's degree from an accredited college or university and three years of administrative or professional experience developing or applying policies and regulations in medical assistance, health insurance, federal or State entitlement programs.
Possession of a Master’s degree from an accredited college or university in the related field of work.
U.S. Armed Forces military service experience as a commissioned officer in Operational Analysis classifications or Health Services Management specialty codes in the health-related field of work on a year-for-year basis for the required experience.

Nice To Haves

Experience interpreting and applying federal and state Medicaid regulations, policies, and procedures related to provider and recipient appeals, sanctions, exclusions, and terminations.
Experience coordinating administrative appeals and ensuring compliance with procedural requirements, including preparing reports, case documentation, and recommendations for program staff.
Experience using Medicaid-related databases and information systems, such as the Maryland Medicaid Information System (MMIS), Long Term Services and Supports (LTSS), In Home Supports and Assances (ISAS), Medicaid Appeals Database, and Medicaid Provider Database, or comparable healthcare program systems.
Experience collaborating with federal agencies, state Medicaid programs, and internal stakeholders to exchange program integrity information, implement regulatory requirements, and support provider enrollment, exclusion, and sanction activities.
Strong analytical, organizational, and communication skills, with experience developing process improvements, interpreting complex regulations, and participating in the implementation or enhancement of healthcare information systems.

Responsibilities

Interpret and apply Federal and State regulations and policies to all provider and recipient appeals within the Medicaid Program.
Assist in the execution of applicable Federal and State exclusion and termination regulations and policies to make programmatic updates when acting to terminate, suspend and sanction providers.
Coordinate and act as a liaison with other state Medicaid programs as well as federal entities regarding exchanging termination and exclusion data.
Prepare reports for Medical Care Program staff regarding appeals and excluded providers.
Coordinate all appeals and ensure Program staff adheres to procedural requirements of the appeals process.