Member Appeals Liaison
About The Position
Trillium Health Resources is a Tailored Plan and Managed Care Organization (MCO) serving 46 counties across North Carolina. We manage services for individuals with serious mental health needs, substance use disorders, traumatic brain injuries, and intellectual/development (IDD) disabilities. Our mission is to help individuals and families build strong foundations for healthy, fulfilling lives. Trillium believes that empowering others begins with supporting our team. We offer our employees a collaborative, mission-driven work environment, competitive benefits and work-from-home options for most positions, and opportunities for professional growth in a diverse inclusive culture. Every day, our work changes lives – from children thriving through early intervention and school-based therapies, to adults with severe mental illness living independently and contributing to their communities. If you are looking for a unique opportunity to make a tangible impact on the lives of others, apply today!
Requirements
- Must meet Qualified Professional (QP) status: Fully licensed by the NC governing board regulating Human Services professions; OR Fully licensed RN who is licensed to practice in the state of NC by the NC Board of Nursing who also has four (4) years of full-time experience with the MH/DD/SA population served. OR A graduate of a college or university with a master’s degree in a human service field and has one year of full-time, pre or post-graduate degree accumulated MH/DD/SA experience with the MH/DD/SA population, or a substance abuse professional who has one year of full-time, pre or postgraduate degree accumulated supervised experience in alcoholism and drug abuse counseling; OR A graduate of a college or university with a bachelor's degree in a human service field and has two years of full-time, pre or post-bachelor's degree accumulated MH/DD/SA experience with the MH/DD/SA population, or a substance abuse professional who has two years of full-time, pre or post bachelor's degree accumulated supervised experience in alcoholism and drug abuse counseling; OR A graduate of a college or university with a bachelor's degree in a field other than human services and has four years of full-time, pre or post-bachelor's degree accumulated MH/DD/SA experience with the MH/DD/SA population, or a substance abuse professional who has four years of full-time, pre or post-bachelor's degree accumulated supervised experience in alcoholism and drug abuse counseling.
- Must have a valid driver’s license.
- Must reside within North Carolina.
- Must be able to travel within catchment as required.
Nice To Haves
- License and/or certification may be accepted as noted above
- Degree in a medical field
- Prior Medicaid appeals experience
- Experience working in an integrated health practice setting or as an integrated health care manager
Responsibilities
- Identifying and closing care gaps in the course of Medicaid appeals decisions.
- Researching cases prior to mediations and/or State Fair Hearings before the North Carolina Office of Administrative Hearings.
- Participating in case staffings with the Appeals and Medical teams.
- Communicating with members, guardians, providers, and care managers before and after mediations and State Fair Hearings.
- Participating in mediations and State Fair Hearings.
- Documenting coordination efforts and outcomes.
- Research treatment history, current medical needs, alternative treatment options, access to providers, and available natural supports for members requesting mediations and State Fair Hearings (SFHs).
- Participate in member appeal mediations and SFHs in order to gather information on necessary follow-up activities.
- Consult with the legal team on strategy for mediations and SFH.
- Communicate with members, guardians, providers, and/or care managers to ensure any recommendations and/or court orders are enacted following the appeals process.
- Prepare supportive evidence for the legal team to use during SFHs.
- Perform additional duties as needed to support the appeals process.
Benefits
- Competitive benefits
- Work-from-home options for most positions
- Health Insurance with no premium for employee coverage
- Flexible Spending Accounts
- 24 days of Paid Time Off (PTO) plus 12 paid holidays in your first year
- NC Local Government Retirement Pension (defined-benefit plan)
- 401k with 5% employer match and immediate vesting
- Public Service Loan Forgiveness (PSLF) qualifying employer
- Quarterly stipend for remote work supplies
Stand Out From the Crowd
Upload your resume and get instant feedback on how well it matches this job.
What This Job Offers
Job Type
Full-time
Career Level
Mid Level
