Appeals Specialist

We are looking for the best and the brightest problem-solvers who are dedicated to changing the way health care is delivered and are passionate about creating a better model for our national health care system. We offer a professional working environment, competitive salaries and excellent benefits. As we continue to grow, we are seeking an experienced Management Information System Director to join our Detroit, Michigan, office.

Washington, DC

Healthcare Company

Our task is to make sure that you and your eligible family members are enrolled and receiving Medicaid or Alliance Benefits. Our mission is to help our D.C. neighbors receive the care and services needed to lead a long and healthy life.

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Overview: <p>The Appeals Specialist supports the Appeals and Grievances Manager in the investigation, coordination and resolution of all member grievances, appeals, complaints, and related complex issues, in accordance to THP&rsquo;s District contract guidelines.&nbsp; This role ensures that these issues are resolved within the mandatory guidelines as established by state and federal regulatory agencies and in accordance with THP policy.</p>
Responsibilities: <ul> <li>Investigate issue, research and collect all information necessary for a determination to be made.</li> <li>Communicate both verbally and in writing with Members, Providers, and others, as necessary, to collect and research all relevant documents and background information, and provide oral notifications of resolution.</li> <li>Consult with THP&rsquo;s Utilization Management (UM), Clinical Pharmacist and Medical Director, and other Plan staff as appropriate; and work collaboratively with physician offices and pharmacies to identify problems and develop solutions.</li> <li>Supervises, oversees, implements and administers all aspects of the appeals system processes consistent with NCQA requirements for providers.</li> <li>Generate all correspondence (i.e. acknowledgment and resolution letters) to members, providers and vendors as required to comply with all relevant rules, regulations policies.</li> <li>Request, collect and log all supporting documentation and related data including, but not limited to medical records, prior authorizations, member and/or practitioner/provider statements, claims, medical groups; maintain computer based records and history of each case in addition to hard copy case files.</li> <li>Complete and submit monthly appeal tracking reports for Compliance department and DHCF.</li> <li>Maintain the appeals and grievance log to track and ensure compliance throughout the investigation process.</li> <li>Ensure that the acknowledgment and resolution letters comply with DHCF guidelines and time frames.</li> <li>Collaborate with the General Counsel to prepare and submit all related documentation for Fair Hearings, external audits, THP position statement preparation.</li> <li>Reviews, analyzes, compiles data, recommends and reports on individual and vendor appeals to the Operations Manager, Director of Operations, Compliance Department and DHCF as appropriate and required.</li> <li>Maintain a current level of knowledge regarding Center for Medicare and Medicaid Services (CMS), and other regulatory agencies.</li> <li>Performs other duties of a similar nature and level as assigned.</li> </ul>
Requirements: <ul> <li>Bachelor&rsquo;s Degree in Business Administration or Health Related Field</li> <li>A minimum of two (2) years of grievance and/or appeals handling experience.</li> <li>Supervisory or lead work experience preferred.</li> <li>Experience working with health care benefits or DC Medicaid.</li> <li>Principles and practices of the managed health care systems, and medical</li> <li>administration and NCQA Accreditation standards.</li> </ul>