Medicare Advantage Plan Appeals Specialist

Encompass Health • Vestavia Hills, AL

5d • Onsite

About The Position

The Medicare Advantage (MA) Plan Appeals Specialist coordinates the Medicare Advantage appeals process for claims made by hospital patients seeking insurance coverage for their hospital stays. The Specialist works with hospital patients, hospital personnel, physicians, in-house counsel, and outside counsel throughout the multiple levels of the appeals process. The Specialist is a member of the Regulatory Enrollment, Approvals & Licensure (REAL) Department.

Requirements

• Bachelor’s degree required.
• Experience in a legal setting is preferred.

Responsibilities

• Understands the entire Medicare Advantage (MA) plan appeals process and CMS rules pertaining to appeals.
• Works with patients, hospital staff, and physicians to obtain all pertinent records and evidence for appeals.
• Schedules witness interviews and preparation for witness testimony.
• Reviews acute hospital medical records, plan denials, and other patient records to prepare witnesses.
• Ensures appellate administrative records are complete for all cases and have been submitted to the appropriate court, MA plans, and opposing counsel.
• Maintains statistics on all MA plan appeals and provides reports as requested by leadership.
• Works with in-house and outside counsel to prepare cases for hearings, coordinate case assignments, and assist with the preparation and filing of appeals to the Medicare Appeals Council or other courts of jurisdiction.
• Understands how to complete various filings and reviews hospital filings to ensure accuracy. Assists hospitals in correcting filings, as necessary.
• Monitors and reports on all administrative hearings related to assigned appeals.
• Understands the necessary filing timelines and ensures that all deadlines are met.
• Works with hospital and Home Office leadership to resolve issues.
• Escalates issues appropriately.
• Conducts independent research accurately and efficiently.
• Retains all documents using the relevant electronic data systems.
• Responsibly and securely stores confidential information and protected health information.
• Collaborates with team members, sharing information, best practices, and resources with peers.
• This position must sit at our Home Office in Birmingham, AL

Benefits

• Affordable medical, dental and vision plans for full-time and part-time employees and their families.
• Generous paid time off that accrues over time.
• Tuition reimbursement and continuing education opportunities.
• Company-matching 401(k) and employee stock purchase plans.
• Flexible spending and health savings accounts.
• A community of people who love what they do.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level