Temporary Health Plan Appeals Specialist - Hybrid

Martin's Point Health Care•Portland, ME

16h•Hybrid

About The Position

Martin's Point Health Care is seeking a Temporary Health Plan Appeals Specialist to process member appeals, non-participating provider pre- and post-service appeals, and participating provider pre-service appeals for Medicare and the US Family Health Plan (USFHP). The Specialist works with Care Managers, Medical Directors, Compliance partners, and other internal and external stakeholders to support a comprehensive appeals management process. The role requires advanced expertise in appeals and grievances, case classification, claims processing, and health plan benefits. The Specialist independently investigates complex cases, manages multiple work queues within regulatory timeframes, communicates with members, providers, review entities, and internal partners, and prepares compliant case correspondence and files. The position also supports audits, second-level appeals, training, process improvements, policy and workflow updates, system testing, and regulatory changes. The Specialist serves as a subject matter expert on TRICARE, USFHP, and relevant CMS appeals guidance and partners with clinical staff on appeals requiring clinical determinations.

Requirements

Bachelor's degree or equivalent combination of experience and education.
Strong written and verbal communication skills.
Effective time-management and organizational skills.
Strong interpersonal skills and ability to collaborate with internal and external clients.
Strong customer service skills.
Ability to meet deadlines, prioritize, and manage multiple tasks while maintaining focus.
Demonstrated understanding of and alignment with Martin's Point values.
Track record of high-quality, accurate work and attention to detail.
Strong analytical, problem-solving, and mathematical skills.
Proficiency in Microsoft Office applications, including Word, Excel, and PowerPoint.
Self-driven and able to work independently with sound judgment.
Ability to take appropriate initiative and seek input or advice when appropriate.
Ability to handle confidential and sensitive information discreetly and professionally.
Ability to manage high volumes of work while maintaining accuracy and timeliness.
Ability to maintain required decision-making and communication timeframes after hours and during holidays.

Nice To Haves

Five or more years of experience in a managed care plan.
Knowledge of Medicare Advantage and/or TRICARE appeals processes and regulations.

Responsibilities

Process Medicare Advantage and USFHP appeals and grievances, including case classification and organization and coverage determinations.
Apply knowledge of claims processing and health plan benefits to make decisions and reprocess claims in accordance with regulatory and internal policies.
Conduct complex investigations involving claims, provider credentialing, authorization processing, timeliness, and plan benefit design.
Manage multiple work queues, including inbound mail, fax, voicemail, internal communication platforms, and the electronic Appeals management system, in accordance with regulatory timeframes and internal performance policies.
Communicate with external downstream entities, provider offices, customers, and internal business partners about appeal-related matters.
Draft and issue regulatorily compliant communications based on analysis of each case.
Create and manage case files and submit cases to required review entities, such as QIO and DHA; serve as the key contact and track cases through completion.
Prepare files and participate in internal and external audits, including DHA, NCQA, and CMS reviews.
Prepare files for second-level appeals through DHA or ALJ.
Support cross-department training and workflows for complex appeals, health plan appeals training, trend reporting, and general appeals oversight.
Conduct provider and beneficiary outreach to investigate and resolve appeals.
Review and update policies, procedures, forms, workflows, and letter templates semi-annually.
Evaluate and implement improvements and operational efficiencies in case classification and appeals processing.
Participate in and conduct internal system upgrade testing, and support annual benefit development and implementation of regulatory changes affecting appeals.
Serve as a daily resource for staff and partner departments on questions and appeals-related escalations.
Serve as the subject matter expert on TRICARE and USFHP appeals manuals and CMS Part C and Part G Organization Determinations and Grievances guidance.
Partner independently with Medical Directors and clinical support staff on appeals requiring clinical decision-making determinations.
Maintain required decision-making and communication timeframes, including after-hours and during holidays.
Demonstrate the organization's mission, vision, and core values.