Appeals Specialist II

Join Martin's Point Health Care - an innovative, not-for-profit health care organization offering care and coverage to the people of Maine and beyond. As a joined force of "people caring for people," Martin's Point employees are on a mission to transform our health care system while creating a healthier community. Martin's Point employees enjoy an organizational culture of trust and respect, where our values - taking care of ourselves and others, continuous learning, helping each other, and having fun - are brought to life every day. Join us and find out for yourself why Martin's Point has been certified as a "Great Place to Work" since 2015.
 

Position Summary
 Medicare and US Family Health Plan (USFHP) Appeal Specialists are responsible for processing of all member appeals, non-participating provider pre- and post-service appeals, and participating provider pre-service appeals. The Specialists collaborates with Care Managers, Medical Directors and Compliance partners, as well as other internal and external partners to ensure a comprehensive appeals management process.
Job Description

Specialist II Key Outcomes:

• Serves as daily resource for staff and partner department questions, escalating unanswered questions
• Oversees initial and cross-training of appeals team members
• Oversees the creation and maintenance of training materials for partner health plan teams
• Oversees the tracking and maintenance of appeals department workflows, job aids, and policies
• Maintains calendar and workplan for USFHP and GA audits and accreditation

Overall Key Outcomes:

• For Medicare Focused Specialist:
  • Researches, processes and resolves Part C reconsiderations with 100% compliance
  • Prepares for, and participates in CMS, NCQA, and Health Plan audits
  • Serves as the subject matter expert for Part C appeals Medicare Managed Care Manuals

• For US Family Health Plan Focused Specialist:
  • Researches, processes and resolves all appeals in accordance with Tricare and NCQA guidelines.
  • Serves as the subject matter expert for TRICARE and US Family Health Plan manuals and benefits pertaining to Member Appeals

• Prepares appeals documentation within contractual and regulatory requirements
• Independently manages multiple work queues, streams of correspondence from providers and members
• Determines the nature of appeals and correspondences and ensures adherence to Standard Operating Procedures (SOP) to determine next steps
• Evaluates medical claims and coverage policy documentation to determine validity of the appeal
• Data entry of appeals to track case details, correspondences, and monitor timeliness of resolution
• Maintains case files in organized and secure manner, both electronically and written
• Conducts telephone work with members, providers and third-party administrators
• Prepares case files on clinical member and provider appeals for review by clinical team members
• Prepares and sends appeal case files for all appeal levels in accordance with regulatory requirements
• Responsible for ensuring and monitoring effectuation of all decisions as a result of the appeal process
• Works with leadership to develop appropriate policies and procedures
• Brings trends and training opportunities to supervisors and management as appropriate
• Works collaboratively and effectively with all other departments and functions to maximize operational efficiency and service and ensure consistency in addressing appeals issues
• Maintains confidentiality while providing quality customer service to internal and external customers
• Cross-trains to perform either Medicare or USFHP Appeals Specialist functions as needed

Education/Experience:

• Bachelor’s Degree or equivalent experience and education
• 5+ years experience in managed care plan required; knowledge of Medicare Advantage (for Medicare Specialist) or TRICARE (for USFHP Specialist) appeals processes and regulations strongly preferred

Skills/Knowledge/Competencies (Behaviors):

• Demonstrates an understanding of and alignment with Martin’s Point Values.
• Excellent written and verbal communication skills
• Effective time management skills and organization skills
• Must have a track record of producing high-quality work: highly accurate, demonstrates attention to detail, and reflects well on the organization
• Strong interpersonal skills and the ability to collaborate with internal and external clients
• Excellent customer services skills
• Strong analytical, problem-solving and mathematical skills
• Proficiency in Microsoft Office applications (Word, Excel, PowerPoint)
• Strong organizational skills and able to meet deadlines (ability to prioritize and multi-task while maintaining focus on objectives).
• Self-driven and self-motivated: ability to function independently with sound decision making
• Take appropriate initiative while soliciting input/advice appropriately
• Ability to handle confidential and sensitive information in a discreet and professional manner.
• Ability to handle high volume of work while maintaining accuracy and timeliness requirements

Required License(s) and/or Certification(s):

None

We are an equal opportunity/affirmative action employer.

Do you have a question about careers at Martin’s Point Health Care? Contact us at: [email protected]