Job Location: Troy, MI
Job Detail:
General Summary
Responsible for the prompt and thorough investigation of medical, transportation, and pharmacy member appeals and grievances for Health Alliance Plan’s (HAP’s): Commercial, Medicare Advantage, Medicare-Medicaid Program (MMP), and Medicaid lines of business. Analyst must identify trending issues on an ongoing basis and provide root/cause analysis when required. Analyst will work with HAP’s medical directors, nurses, pharmacists, Legal department, and other subject matter experts to determine appropriate outcomes for all cases. In addition, in this role the analyst will be required to keep abreast of regulatory requirements from State and Federal agencies and speak before members, senior leaders and other key stakeholders to present appeal cases on an ongoing basis. The analyst will also provide necessary support for audits and the development of desk level procedures.
Principle Duties And Responsibilities
- Conduct the primary investigation and resolution of member appeals and grievances following established guidelines from: The Center for Medicaid and Medicare Services (CMS), MAXIMUS Federal Services, Department of Labor (DOL), Department of Insurance and Financial Services (DIFS), Michigan Department of Health and Human Services (MDHHS), National Committee for Quality Assurance (NCQA), Office of Personnel Management (OPM), MI Health Link, and Better Business Bureau (BBB).
- Demonstrate strict adherence to the Centers for Medicare and Medicaid (CMS), MI Health Link (MMP), and Michigan Department of Health and Human Services (MDHHS) contracts in the responses to members and regulatory agencies.
- Provide concise and thorough written responses to members and regulatory agencies regarding the findings of their investigations
- Perform case pre-analysis, and procure appropriate medical records and supporting documentation prior to sending case to internal stakeholders for subject matter expert reviews
- Prepare cases for presentation during pertinent hearings (e.g. Administrative Law Judge hearings, MAXIMUS Committee Meetings, State Fair Hearings, Second-Level Member Hearings)
- Perform other related duties as assigned.
Education/Experience Required
- Associate’s Degree in healthcare or a related field.
- At least three of the following bulleted items is needed in combination with successful experience with business writing which will be demonstrated by passing a writing assessment:
- Minimum of two (2) years of experience working in a managed care environment investigating appeals.
- Minimum of two (2) years of experience working with Medicare, Commercial, and Medicaid/MMP appeals and grievances.
- Minimum of two (2) years of experience working in a managed care environment investigating and resolving complaints or grievances.
- Minimum of two (2) years of experience working on utilization management platform-processing authorizations.
- Minimum of two (2) years of experience compiling data for appeal review with regulatory entities.
- Minimum of two (2) years of experience performing quality management case reviews.
- Requires a successfully complete written assessment.
- Must demonstrate strong analytical and critical thinking skills.
- Strong writing skills.
- Must demonstrate excellent problem-solving techniques.
- Must possess a very high degree of patience, maturity, empathy, tact and diplomacy and be able to work with all levels of people within the organization.
- Must possess a high degree of poise and good judgment in responding to inquiries from customers with varying attitudes and have excellent written, listening and verbal communication skills.
- Must be flexible and handle multiple priorities through organizational and time management skills.
- A demonstrated ability to work in a Windows environment, HAP’s current documentation system (Pega A&G, Pega CRM and Microsoft Word).
- Demonstrated knowledge of the Medicare Advantage, Federal Government, Medicare benefits, all Commercial including Self-Funded benefit guides, contracts and riders, eligibility and direct pay programs and rates.
- Demonstrated knowledge of billing/claims and customer service functions in a healthcare environment.
- Knowledge of medical terminology.
Certifications/Licensures Required
- Minimum of two (2) years of experience as a Licensed Practical Nurse (LPN) in the State of Michigan preferred.
- Minimum of two (2) years of experience as a Registered Health Information Technician (RHIT) preferred.
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