UM Appeals Specialist (Hybrid)

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
• Public Service Loan Forgiveness Qualifying Employer

See attachment for additional details. 

Office Location:  Available for the Gastonia, NC location.  Hybrid (must work in the office 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 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
• 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 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)

Liaison:  

• 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

Misc:  

• 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.

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 and Experience Required: Bachelor’s Degree and two (2) years of Human Services/healthcare experience or a comprehensive combination of education and experience may be accepted. 

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

Licensure/Certification Requirements: None Required