Medicare Appeals Specialist - JHP

Jefferson Health Plans • Philadelphia, PA

8d

About The Position

The Medicare Appeals Specialist is responsible for independently coordinating Part C & Part D Expedited, Pre-Service and Standard Appeals and Grievances from receipt to resolution. The Specialist must have a broad knowledge of products and benefits as well as have an understanding of regulatory requirements and timeframes. Essential Functions: Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. Able to work in a constant state of alertness and safe manner Must have a thorough understanding of Health Plan operations and business unit processes, work flows and system requirements, including but not limited to, authorizations, billing, claims and regulatory compliance and plan benefits. Work closely with Medical Directors and Claims staff to resolve appeals timely and accurately. Ensures the timely and accurate documentation, review, routing and tracking of member issues in compliance with regulations established by external regulating bodies and applicable state and federal laws. Handles multiple issues and prioritizes appropriately with the ability to organize work to meet deadlines. Conducts research by speaking with members and providers, reviewing member’s records and benefit plan and obtaining responses from various business areas. Demonstrates ability to process complex information and deliver the information both verbally and written, in a professional, clear, concise and articulate manner. Requires excellent interpersonal skills in order to communicate and work with multiple constituents and be able to recognize sensitive issues and when to escalate to Management. Must provide formal well-written communication to members and providers in conjunction with the complaint, grievance and appeal process and independently handle high volume of cases. Prepares case files for Independent Review Entities that are well organized, contain relevant documentation and are processed within the required timeframes. Maintains corporate policies and procedures and other formal documents pertinent to the complaint, grievance and appeal functions and collect mandatory data for CMS Universes. Be available to participate in the on-call process during weekends and holidays on a rotation basis. Other duties as assigned.

Requirements

• Strong communication (written/oral), and organization skills with great level of attention to detail
• Ability to interpret medical terminology, regulations/statutes and apply them without direct supervision
• Exceptional presentation skills, autonomous, productive and takes initiative.
• Ability to handle multiple responsibilities and changing priorities
• Advanced knowledge of Microsoft Office (Excel and Word.
• CCMS, MACESS, and relational databases

Responsibilities

• Coordinating Part C & Part D Expedited, Pre-Service and Standard Appeals and Grievances from receipt to resolution.
• Work closely with Medical Directors and Claims staff to resolve appeals timely and accurately.
• Ensuring timely and accurate documentation, review, routing and tracking of member issues in compliance with regulations.
• Conducting research by speaking with members and providers, reviewing member’s records and benefit plan and obtaining responses from various business areas.
• Providing formal well-written communication to members and providers in conjunction with the complaint, grievance and appeal process and independently handle high volume of cases.
• Preparing case files for Independent Review Entities that are well organized, contain relevant documentation and are processed within the required timeframes.
• Maintaining corporate policies and procedures and other formal documents pertinent to the complaint, grievance and appeal functions and collect mandatory data for CMS Universes.
• Participate in the on-call process during weekends and holidays on a rotation basis.
• Other duties as assigned.

Benefits

• Jefferson offers a comprehensive package of benefits for full-time and part-time colleagues, including medical (including prescription), supplemental insurance, dental, vision, life and AD&D insurance, short- and long-term disability, flexible spending accounts, retirement plans, tuition assistance, as well as voluntary benefits, which provide colleagues with access to group rates on insurance and discounts.
• Colleagues have access to tuition discounts at Thomas Jefferson University after one year of full time service or two years of part time service.
• All colleagues, including those who work less than part-time (including per diem colleagues, adjunct faculty, and Jeff Temps), have access to medical (including prescription) insurance.

What This Job Offers

• Job Type: Full-time
• Career Level: Entry Level
• Education Level: No Education Listed
• Number of Employees: 501-1,000 employees