Medicare Non Contracted Provider Appeals Analyst

Corewell Health • Grand Rapids, MI

1d • Onsite

About The Position

This position will support our non-contracted provider post claim appeals submitted to the health plan. Job Summary Responsible for the analysis, research and completion of complex member appeal investigations. Effectively administer all steps of the member appeal and fair hearing review processes for all non-Medicare products to thoroughly investigate appeal requests, leveraging critical thinking skills, gathering relevant information from enterprise-wide systems, and collaboration to resolve issues whenever possible. Ensure compliance with all mandated, legislative, regulatory and accreditation requirements. Assist customers and staff throughout the process by providing complete information and follow up on a timely basis. Ensure committee, State and Federal decisions are properly implemented. Assist the Lead, Supervisor and/or Manager in coordinating activities and in the development/collection of materials required to meet and demonstrate compliance to all state, federal and accrediting organization requirements. Prepares and presents education to internal departments. Serves as a mentor/trainer to other team members. The Senior Appeals Analyst makes decisions on moderately complex issues regarding technical approach for project components, and work is performed without direction. Exercises latitude in determining objectives and approaches to assignments. Essential Functions Responsible for complex and thorough investigation of appeals, external complaints, and fair hearing reviews including: formulate action plan to ensure all activities are completed by the regulatory time line, gather all relevant information for the appeal request (external medical records, internal documentation from enterprise-wide systems including: claims payments, billing and enrollment, care management, medical, pharmacy and behavioral health authorizations, customer service interactions, prescription claims, medical policies, and plan documents). Evaluate information gathered to ensure all benefit language outlined in plan documents have been interpreted accurately and consistently, determine if pharmacy and medical policies have been applied appropriately or if additional clinical information is available after the original decision Resolve appeal and fair hearing requests prior to committee or fair hearing review, when appropriate, including collaboration internally with all levels within the organization including Executives, Market Segment Leaders, Medical Directors, Legal, Medical Operations, Enterprise Operations, Customer Service, and leaders throughout the organization and externally with providers, agents, members, and employer groups. If not resolved prior to the Appeal Committee process, prepare the presentation of all relevant facts and present concise yet comprehensive information to the appropriate committee(s) to ensure a full and fair review; Coordinate and manage reviews with Independent Review Organizations (IRO) when appropriate; work with Medical Directors to suggest and solicit appropriate questions for IRO response. Ensure all required documentation and files are complete, organized and secure to meet State, Federal, Health Plan and NCQA requirements. Effectuate Appeal Committee and Department of Insurance and Financial Services (DIFs) directed decisions and ensure outcomes are effectively communicated (oral and written) following regulatory and NCQA requirements. Perform quality assurance reviews for case files, decision forms, documentation and logs to ensure they are complete, organized and secure and ensure all procedures are followed and time line requirements are met, including implementation of all Committee, and State or Federal decisions. Act as lead for expedited requests, gathering relevant information, working with Medical Director to determine if criteria is met. If expedited criteria is met, ensure investigation, review, decision, and completion within required 72 hour time line. Communicate outcome to member. Provide technical, product, policy and procedure education and training for new and existing staff. Provide education and communicates training needs to Customer Service Leadership, when appropriate, to avoid unnecessary appeals and/or expedited requests. Analyze and investigate requests for fair hearings; gather relevant information and prepare comprehensive documentation as “evidence” for the State of Michigan Administrative Law Judge. Ensure timely submission of documentation prior to the scheduled hearing. Represent Priority Health during the fair hearing process with the member and/or member’s representative (i.e. attorney, physician, agent) and the State of Michigan Administrative Law Judge. Present facts and legal evidence in a comprehensive and professional manner to demonstrate the rationale for the Priority Health decision in order for the State of Michigan Judge to make a final determination. Facilitate Appeal Committee meetings to ensure full and fair review. Track all activity including communication for each appeal case by entering complete documentation of issues and related follow-up, ensuring all customers receive required correspondence according to time line requirements and to ensure all regulatory reporting requirements are met. Collaborate with cross-functional departments to implement improvements to member experience, medical policies, legal documents, member materials, departmental processes and workflow. Conducts root cause analysis to determine corrective actions related to the appeals process by researching systemic issues to determine course corrections Apply strong analytical skills and business knowledge to investigation, analysis and recommendation of solution Communicates, collaborates and acts as a consultant to internal and external customers in order to resolve complex issues.

Requirements

• Associate's Degree or equivalent
• 5 years of relevant experience Grievance & or Appeal Analyst or related experience

Nice To Haves

• Bachelor's Degree or equivalent
• 3 years of relevant experience Member or Provider Customer service, Claims, Legal and/or enrollment/eligibility
• Working knowledge of Priority Health systems for claims payment, care management, authorizations, customer service interactions, pharmacy, Rx profiles, medical policies, and plan documents for all non-Medicare product lines (Commercial Group, Commercial individual, PH Insurance Company (PHIC), Self-funded, Government Programs – Medicaid)
• Extensive knowledge of managed care products and regulatory and accreditation requirements; Maintain knowledge of policies and procedures, including medical policies which may impact the grievance, appeal and review processes

Responsibilities

• Responsible for complex and thorough investigation of appeals, external complaints, and fair hearing reviews including: formulate action plan to ensure all activities are completed by the regulatory time line, gather all relevant information for the appeal request (external medical records, internal documentation from enterprise-wide systems including: claims payments, billing and enrollment, care management, medical, pharmacy and behavioral health authorizations, customer service interactions, prescription claims, medical policies, and plan documents).
• Evaluate information gathered to ensure all benefit language outlined in plan documents have been interpreted accurately and consistently, determine if pharmacy and medical policies have been applied appropriately or if additional clinical information is available after the original decision
• Resolve appeal and fair hearing requests prior to committee or fair hearing review, when appropriate, including collaboration internally with all levels within the organization including Executives, Market Segment Leaders, Medical Directors, Legal, Medical Operations, Enterprise Operations, Customer Service, and leaders throughout the organization and externally with providers, agents, members, and employer groups.
• If not resolved prior to the Appeal Committee process, prepare the presentation of all relevant facts and present concise yet comprehensive information to the appropriate committee(s) to ensure a full and fair review; Coordinate and manage reviews with Independent Review Organizations (IRO) when appropriate; work with Medical Directors to suggest and solicit appropriate questions for IRO response.
• Ensure all required documentation and files are complete, organized and secure to meet State, Federal, Health Plan and NCQA requirements.
• Effectuate Appeal Committee and Department of Insurance and Financial Services (DIFs) directed decisions and ensure outcomes are effectively communicated (oral and written) following regulatory and NCQA requirements.
• Perform quality assurance reviews for case files, decision forms, documentation and logs to ensure they are complete, organized and secure and ensure all procedures are followed and time line requirements are met, including implementation of all Committee, and State or Federal decisions.
• Act as lead for expedited requests, gathering relevant information, working with Medical Director to determine if criteria is met. If expedited criteria is met, ensure investigation, review, decision, and completion within required 72 hour time line. Communicate outcome to member.
• Provide technical, product, policy and procedure education and training for new and existing staff.
• Provide education and communicates training needs to Customer Service Leadership, when appropriate, to avoid unnecessary appeals and/or expedited requests.
• Analyze and investigate requests for fair hearings; gather relevant information and prepare comprehensive documentation as “evidence” for the State of Michigan Administrative Law Judge. Ensure timely submission of documentation prior to the scheduled hearing.
• Represent Priority Health during the fair hearing process with the member and/or member’s representative (i.e. attorney, physician, agent) and the State of Michigan Administrative Law Judge. Present facts and legal evidence in a comprehensive and professional manner to demonstrate the rationale for the Priority Health decision in order for the State of Michigan Judge to make a final determination.
• Facilitate Appeal Committee meetings to ensure full and fair review.
• Track all activity including communication for each appeal case by entering complete documentation of issues and related follow-up, ensuring all customers receive required correspondence according to time line requirements and to ensure all regulatory reporting requirements are met.
• Collaborate with cross-functional departments to implement improvements to member experience, medical policies, legal documents, member materials, departmental processes and workflow.
• Conducts root cause analysis to determine corrective actions related to the appeals process by researching systemic issues to determine course corrections
• Apply strong analytical skills and business knowledge to investigation, analysis and recommendation of solution
• Communicates, collaborates and acts as a consultant to internal and external customers in order to resolve complex issues.

Benefits

• Comprehensive benefits package to meet your financial, health, and work/life balance goals.
• Learn more here.
• On-demand pay program powered by Payactiv
• Discounts directory with deals on the things that matter to you, like restaurants, phone plans, spas, and more!
• Optional identity theft protection, home and auto insurance, pet insurance
• Traditional and Roth retirement options with service contribution and match savings
• Eligibility for benefits is determined by employment type and status

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: Associate degree
• Number of Employees: 5,001-10,000 employees