Competitive Compensation & Benefits Package!

Position eligible for – 

• Annual incentive bonus plan
• Medical, dental, and vision insurance with low deductible/low cost health plan
• Generous vacation and sick time accrual
• 12 paid holidays
• State Retirement (pension plan)
• 401(k) Plan with employer match
• Company paid life and disability insurance
• Wellness Programs

See attachment for additional details. 

Office Location: Gastonia, NC (Hybrid - will need to come into the Gastonia office a minimum of 2 days per week)

Projected Hiring Range: Depending on Experience 

Closing Date: Open Until Filled

Primary Purpose of Position:

This position is responsible for implementing and supporting the LME/MCO Medicaid and State appeals process.

Role and Responsibilities:

Implementation of MCO Medicaid and non-Medicaid Appeals Processes: 

• Preparing, proofreading and verifying the accuracy of the LME/MCO notification letters to consumers/legal guardian/legal representatives and providers of reductions, suspensions, terminations or denials of services
• Assisting consumers, 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 consumers/ 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
• Document all contacts with consumer/guardian, reviewer and providers; and establish and maintain the denial and appeals records
• Additional duties as needed to support and/or provide oversight of the appeals process in clinical operations and other organizational departments as deemed applicable

Educate:

• Provide education, support and information to consumers, legal guardians, legal representatives and providers concerning and during the appeals process
• Answer questions about appeals process and assist consumer, legal guardians, and legal representatives in completing appeals forms (Medicaid & Non-Medicaid)

Liaison:

• Serves as a staff liaison for all consumers, 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

Misc:

• Uses tact and diplomacy in communication with consumers, legal guardians, legal representatives, providers and others while working through the appeals process
• Effectively works with other to ensure timeliness of appeals process

Knowledge, Skills and Abilities:

• 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

Education/Experience Required:

Bachelor’s Degree and two (2) years of Human Services/healthcare experience. An equivalent combination of education and experience may be accepted.

Education/Experience Preferred:

Master’s Degree and two (2) years of Human Services/healthcare experience.