Appeals Navigator TERM LIMITED

State of Colorado•Denver, CO

6d•Hybrid

About The Position

This is a TERM LIMITED position funded through 2/29/2028. The Department of Health Care Policy & Financing (HCPF) oversees and operates Health First Colorado (Colorado's Medicaid Program), Child Health Plan Plus (CHP+), and other state public health programs for qualified Coloradans. Our mission is to improve health care equity, access and outcomes for the people we serve while saving Coloradans money on health care and driving value for Colorado. We are committed to increasing the diversity of our staff and providing culturally responsive programs and services. Therefore, we encourage responses from people of diverse backgrounds and abilities. The Legal Division exists to support the legal and privacy issues of the Department. Included in the Legal Division are Benefits Coordination, the data response team consisting of the Privacy Officer and the Legal Analyst, and the Policy Specialist responsible for the submission of State Plan waivers and amendments. The Legal Division is responsible for maintaining the Protected Health Information database that houses information regarding powers of attorney and authorizations. As well, the Legal Division is responsible for the privacy hotline. The Division assists the Department in complying with all applicable federal and state statutes, federal and state regulations, and other policy considerations.

Requirements

Six (6) of professional experience in public policy or a health or social services-related field involving working knowledge of the Medicaid program, policy research, analysis and implementation, member communication and appeals processes, and stakeholder engagement.
Bachelor's degree from an accredited institution in Public or Healthcare Policy, Healthcare Administration or Management, Public Health, Social Work, Law Degree or related field AND Two (2) years of professional experience in public policy or a health or social services-related field involving working knowledge of the Medicaid program, policy research, analysis and implementation, member communication and appeals processes, and stakeholder engagement.
Ability to read, analyze, understand, and apply laws, rules, policies and procedures.
Exceptional oral and written communication skills, including the ability to verbally communicate to a diverse audience and the ability to complete reports and communications in a clear, accurate, and concise manner.
Interpersonal skills, including the ability to build strong relationships and work collaboratively with a variety of different stakeholders, both internal and external.
Positive attitude and demonstrated ability to remain patient and compassionate when dealing with difficult customer interactions.
Demonstrated customer service skills, including the ability to use de-escalation techniques to resolve difficult conversations.
Ability to handle sensitive and/or highly confidential information in a professional and ethical manner, and in accordance with state and federal laws.
Ability to represent the department in a positive, professional and objective manner, and support a positive workplace environment.
Accountability for work product and attendance.
Demonstrated attention to detail.
Professional demeanor.
Proficiency in the use of PC software applications including Microsoft Office (Access, Word, Excel, PowerPoint, etc.), and Google Suite (Doc’s, Sheets, Drawings, Forms, etc.).
All positions at HCPF are security sensitive positions and require that the individuals undergo a criminal record background check as a condition of employment.
Employees who have been disciplinary terminated, resigned in lieu of disciplinary termination, or negotiated their termination from the State of Colorado must disclose this information on the application.

Nice To Haves

Current experience working with Medicaid and the healthcare industry, including statutes, and regulations.
Experience with program evaluation, data analysis, and policy analysis to identify issues, develop solutions, and recommend policy and programmatic improvements.
Ability to analyze information and evaluate results to choose the best solution and solve problems.
Proven ability to plan, organize, and prioritize, in order to accomplish work assignments and meet strict deadlines.
Relevant State of Colorado experience.

Responsibilities

Serves as a key resource on Medicaid member appeals for staff, Medicaid members, advocates, and stakeholders.
Supports members who may have limited English proficiency, low health literacy, or limited experience navigating Medicaid and the appeals process by translating complex policies into clear, plain language and providing fair, impartial guidance regarding appeals procedures and case-specific questions.
Advises members, staff, and stakeholders on how to effectively navigate the member appeals process.
Collaborates closely with Department and vendor staff to review cases, identify appropriate next steps, and ensure action items are completed within required timelines.
Works collaboratively with member appeals team members to assist in developing hearing strategies and preparing appeals documentation for Department representatives participating in hearings.
Tracks appeal deadlines and maintains related data to support timely and accurate case management.
Collects, analyzes, compares, and summarizes information from multiple sources, including notices, motions, complaints, affidavits, briefs, legal decisions, medical records, and other case-related documentation.
Evaluates appeals cases and operational data to identify opportunities for improvement in databases, processes, metrics, strategies, appeal outcomes, member experience, and Department policies.
Recommends best practices, identifies gaps related to benefits, policies, quality, and access, and contributes to the assessment and development of current and future policies.
Develops collaborative working relationships with internal and external partners to address policy and program challenges, support process improvements, and advance program goals.
Serves as a resource on Medicaid benefits, services, and equipment appeals and interacts regularly with stakeholders and member representatives.
Acts as a backup to the work lead for appeal hearings concerning Medicaid benefits, services, and equipment.
May represent the Department before an Administrative Law Judge (ALJ).
Participates in the pre-hearing appeals process by conducting preliminary case analysis, reviewing medical records and product research, applying negotiation skills, and exercising sound judgment to determine whether cases should be resolved prior to hearing or presented before the ALJ.
Identifies solutions to improve quality and operational efficiency.
May occasionally travel in-state or out-of-state for programmatic or staff development activities as needed.

Benefits

PERA retirement benefits including PERA Defined Benefit Plan, PERA Defined Contribution Plan, plus 401K and 457 plans
Medical , Dental , and Vision insurance coverage
Automatic Short-Term and Optional Long-Term Disability Coverage
Life and AD&D Insurance
Flexible Spending Accounts (FSAs)
Family Medical Leave Act (FMLA) job protection and State of Colorado Paid Family Medical Leave (PFML)
11 Paid Holidays Annually and Accrued Annual and Sick Leave
Accrued Sick Leave for State of Colorado Temporary Employees
Flexplace and Flextime work arrangements
Variety of discounts on services and products available through the State of Colorado's Work-Life Employment Discount Program
Free RTD EcoPass to all eligible State Employees
Credit Union of Colorado Membership Eligibility
Some positions may qualify for the Public Service Loan Forgiveness Program.