Fair Hearing - Medical Insurance

Unison Health•Toledo, OH

About The Position

Unison Health provides a mission-driven work environment focused on staff support, professional growth, and work-life balance. We are committed to helping our employees thrive while making a lasting difference in the lives of children and families. For over 50 years, Unison Health has proudly supported individuals, families, and communities across Ohio. From behavioral health and substance abuse treatment to primary healthcare, we are dedicated to our mission: Making Lives Better.

Requirements

Bachelor’s degree in health administration, Social Work, Public Administration, Legal Studies, or a related field required.
Experience managing Medicaid grievances, appeals, and/or State Fair Hearing processes required.
Working knowledge of Medicaid regulations, including 42 CFR Part 438.
Strong written and verbal communication skills, with the ability to prepare formal appeal summaries and case documentation.
Strong organizational, analytical, and problem-solving skills with attention to detail and regulatory compliance.

Nice To Haves

Master’s degree or advanced credential preferred (e.g., JD, RN, LISW-S, LPCC-S, or equivalent).
Experience representing or supporting cases in Ohio Medicaid State Fair Hearings preferred.
Knowledge of behavioral health, substance use disorder (SUD), and/or long-term services and supports (LTSS) preferred.

Responsibilities

Oversee and manage Medicaid grievances and appeals related to service denials, reductions, suspensions, terminations, and failure-to-act cases in accordance with regulatory requirements.
Ensure Notices of Action are issued and reviewed for compliance, including required timelines, content, appeal rights, and continuation of benefits provisions.
Coordinate with clinical, utilization management, billing, and provider teams to gather documentation and support appeal determinations.
Lead the preparation and coordination of Ohio Medicaid State Fair Hearings, including appeal summaries, hearing packets, and supporting documentation.
Represent or support the organization during hearings before the Ohio Department of Job and Family Services (ODJFS) Bureau of State Hearings.
Provide guidance and training to providers and staff regarding Medicaid appeals, grievances, hearing rights, and regulatory requirements.
Monitor, identify, and escalate compliance concerns, including potential issues related to denials, recoupments, and adverse benefit determinations.
Analyze grievance and appeal trends, prepare reports for leadership, and recommend quality improvement and risk mitigation strategies.