Appeals Manager

State of North Carolina

1d • Hybrid

About The Position

The purpose of the Division of Health Benefits Legal Office is to support the legal and compliance functions for Medicaid within the State of North Carolina. In addition, the Legal Office provides executive oversight and leadership for the Hearings and Appeals Unit. The purpose of the Hearings and Appeals Unit is to provide coordination of fee for service appeals and grievances by providers, beneficiaries and claimants and provide oversight and monitoring of appeals and grievances under managed care. The unit also manages due process compliance which includes training, tactical oversight, and stakeholder coordination. The unit coordinates with the DOJ, Attorney General’s Office and other external stakeholders. The purpose of this position is to work as an integral member of the Medicaid Appeals team that provides oversight of appeal and grievance functions, processes, and initiatives, troubling shooting issues, and other tasks and items that arise for Medicaid Beneficiary Appeals and grievances and Provider Claim appeals.

Requirements

• Master's degree in the area of assignment from an appropriately accredited institution and three years of experience in a closely related program; or Bachelor's degree in the area of assignment field from an appropriately accredited institution and five years of experience in a closely related program; or an equivalent combination of education and experience.

Nice To Haves

• Proven ability in establishing and maintaining effective working relationships with internal and external stakeholders through verbal and written communication skills.
• Knowledge and understanding of the healthcare industry and associated hearings, appeals and due process regulatory requirements.
• Knowledge of Medicaid programs, current health initiatives, and the understanding of program management including operational design and implementation.
• Ability to exercise judgement and discretion in establishing, applying, interpreting, and evaluating policies and procedures.
• Demonstrated proficiency in Microsoft Office products such as Excel, Outlook, and Word.

Responsibilities

• Research, analyze, and interpret varying laws, regulations, and policies to ensure full compliance with all due process requirements.
• Engage in personnel administration to include but not limited to recruiting, coaching, selecting, and managing employees, including disciplinary and termination actions as needed; delegating to staff members; encouraging and fostering professional development; establishing effective professional goals and work plan objectives.
• Assist with monitoring provider and vendor compliance with laws and regulations regarding Medicaid appeals to ensure compliance with appeal rights afforded to all NC Medicaid beneficiaries and providers.
• Update and revise or create NC Medicaid appeal templates as needed for Medicaid vendors and internal DHB units.
• Assist in responding to Medicaid appeal and grievance questions from vendors, DHB, staff, NC representatives on behalf of their constituents.
• Assist in reviewing and commenting on Medicaid appeal and grievance deliverables submitted by PHP (Prepaid Health Plans) or other entities.
• Facilitate the resolution of member grievances that are escalated to the Department.
• Serve as the business owner for the contract with the Office of Administrative Hearings as it relates to State Fair Hearing delegation.
• Serve as the business owner for the Appeals Clearinghouse.

Benefits

• The State of North Carolina offers excellent comprehensive benefits.
• Employees can participate in health insurance options, standard and supplemental retirement plans, and the NCFlex program (numerous high-quality, low-cost benefits on a pre-tax basis).
• Employees also receive paid vacation, sick, and community service leave.
• In addition, paid parental leave is available to eligible employees.

What This Job Offers

• Job Type: Full-time
• Career Level: Manager
• Number of Employees: 1,001-5,000 employees