UM Appeals Specialist (Hybrid)

Partners Behavioral Health Management•Gastonia, NC

6d•Hybrid

About The Position

This position is responsible for implementing and supporting the LME/MCO Medicaid and State appeals process. The role involves preparing, proofreading, and verifying the accuracy of notification letters regarding service reductions, suspensions, terminations, or denials. It also includes assisting members, legal guardians, and representatives in completing appeal requests, following federal, state, and organizational policies, and tracking authorization appeals from initiation to completion. The specialist will collaborate with various stakeholders to ensure due process, monitor reconsideration reviews, and maintain accurate documentation of all contacts and records. Additionally, the position provides education and support to members and providers regarding the appeals process and serves as a liaison for all adverse events.

Requirements

Knowledge of Federal and State regulations on behavioral healthcare denials and appeals processes
National Accreditation knowledge specific to organization
Knowledge of medical records practices and recordkeeping practices, including electronic records and imaging/scanning processes
Knowledge in preparation for legal proceedings including mediation, administrative law courts and other legal processes
Knowledge of agency policies and procedures that pertain to duties
Knowledge of DMA and Division contracts specific to organization
Knowledge of service definitions and DMA clinical policy
Proficiency in Microsoft Office products (Word, Excel, Outlook, PowerPoint, etc.)
Ability to organize multiple tasks and priorities and to effectively manage numerous details
Ability to effectively and accurately manage projects from start to finish
Ability to understand and adhere to amendments and priorities at the State, Federal, Accreditation or contract level
Bachelor’s Degree and two (2) years of Human Services/healthcare experience or a comprehensive combination of education and experience may be accepted.

Nice To Haves

A Qualified Professional (QP) with IDD/BH, Pharmacy and/or Physical Health/Medical experience is preferred.

Responsibilities

Preparing, proofreading and verifying the accuracy of the LME/MCO notification letters to members/recipients/legal guardian/legal representatives and providers of reductions, suspensions, terminations or denials of services
Assisting members/recipients, legal guardians and/or legal representatives in completing appeal requests for the agency
Following federal, state and organizational policies
Receive, track and follow individual authorization appeals from initiation to completion
Work collaboratively with members/recipients/ legal guardian/legal representatives, providers, stakeholders, agency staff and others as necessary to ensure due process of authorization appeals
Monitor the assignment of the local reconsideration review process for each appeal
Timely documentation of all contacts with member/recipient/guardian, reviewer and providers; and establish and maintain the denial and appeals records
Provide education, support and information to member/recipient, legal guardians, legal representatives and providers concerning and during the appeals process
Answer questions about appeals process and assist member/recipient, legal guardians, and legal representatives in completing appeals forms (Medicaid & Non-Medicaid)
Serves as a staff liaison for all member/recipient, legal guardians, legal representative, providers, community stakeholders and the agency staff regarding all adverse events
Responds to questions regarding authorization appeals in a timely manner
Uses tact and diplomacy in communication with members/recipients, legal guardians, legal representatives, providers and others while working through the appeals process
Effectively works with others to ensure timeliness of appeals process
Appropriately responds to or directs questions/concerns and promotes a positive work environment.
Participates in a telephone workgroup rotation to address calls received in the Appeals department.
Other duties as assigned by Supervisor.