Temporary Health Plan Appeals Specialist - Hybrid

Martin’s Point Health Care•Portland, ME

2d•$65,725 - $81,190•Hybrid

About The Position

Martin's Point Health Care is a not-for-profit health care organization serving Maine and beyond. The Health Plan Appeals Specialist processes Medicare and US Family Health Plan (USFHP) member appeals, non-participating provider pre- and post-service appeals, and participating provider pre-service appeals. The position works with Care Managers, Medical Directors, Compliance partners, and other internal and external partners to support comprehensive appeals management. The Specialist handles complex appeals and grievances across Generations Advantage and USFHP, including case classification, organization and coverage determinations, claims review and reprocessing, investigations, communications, case submissions to external review entities, audit preparation, policy and workflow updates, process improvements, and system testing. The role also supports staff and partner departments as a daily resource and subject matter expert on applicable TRICARE, USFHP, and CMS appeals guidance. It requires maintaining regulatory and statutory timelines, including after-hours and holiday processes when necessary.

Requirements

Bachelor's degree or equivalent combination of experience and education.
Excellent written and verbal communication skills.
Effective time-management and organizational skills.
Strong interpersonal skills and ability to collaborate with internal and external clients.
Excellent customer service skills.
Ability to prioritize and manage multiple tasks while meeting deadlines and maintaining focus.
Understanding of and alignment with Martin's Point values.
Track record of high-quality, accurate work with strong 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 initiative while appropriately seeking input and advice.
Ability to handle confidential and sensitive information discreetly and professionally.
Ability to manage high volumes of work while maintaining accuracy and timeliness.

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 member appeals, non-participating provider pre- and post-service appeals, and participating provider pre-service appeals.
Apply advanced knowledge of Generations Advantage and USFHP appeals and grievances, including case classification, organization determinations, and coverage determinations.
Use knowledge of claims processing and health plan benefits to make authorized claims reprocessing decisions in accordance with regulatory and internal policies.
Independently investigate complex cases through claims review, provider credentialing, authorization processing, timeliness evaluations, and plan benefit design review.
Manage multiple work queues, including inbound mail, fax, voicemail, internal communication platforms, and the electronic Appeals management system, in accordance with regulatory timelines and internal policies.
Communicate with external downstream entities, provider offices, customers, and internal business partners about appeals.
Draft and issue compliant communications by analyzing case facts and responding promptly to requests.
Create and manage case files and oversee submissions to required review entities, including 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 and audits.
Prepare files for second-level appeals through DHA or an Administrative Law Judge (ALJ).
Support cross-departmental training and workflows for complex appeals, including appeals training, trend reporting, and general oversight.
Conduct provider and beneficiary outreach to investigate and resolve appeals, including outreach to provider billing offices and facilities.
Independently review and update policies, procedures, forms, workflows, and letter templates semi-annually.
Evaluate and implement process improvements and operational efficiencies for case classification and appeals processing.
Participate in and conduct internal system upgrade testing, support annual benefit development, and implement regulatory changes related to appeals.
Serve as a daily resource for staff and partner departments on questions and appeals escalations.
Serve as a subject matter expert on TRICARE and USFHP manuals related to appeals 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 as needed.
Demonstrate the organization's mission, vision, and core values.