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Medicare Appeals Intake Analyst

Grand Rapids, MI 49525 | Fully Remote

Posted: 05/22/2023 Job Type: Contract Industry: Other (HR, Admin, Mkt, Sales) Job Number: 22800 Pay Rate: $ 20.00 - $ 22.00

Job Description

100% Remote
 Job Summary
 Responsible for the analysis, research, and completion of complex member appeal investigations. Effectively administer all steps of the member appeal and fair hearing review processes for all non-Medicare products to thoroughly investigate appeal requests, leveraging critical thinking skills, gathering relevant information from enterprise-wide systems, and collaboration to resolve issues whenever possible. Ensure compliance with all mandated, legislative, regulatory and accreditation requirements. Assist customers and staff throughout the process by providing complete information and follow up on a timely basis. Ensure committee, State and Federal decisions are properly implemented. Assist the Lead, Supervisor and/or Manager in coordinating activities and in the development/collection of materials required to meet and demonstrate compliance to all state, federal and accrediting organization requirements. Prepares and presents education to internal departments. Serves as a mentor/trainer to other team members.
 The Senior Appeals Analyst makes decisions on moderately complex issues regarding technical approach for project components, and work is performed without direction. Exercises latitude in determining objectives and approaches to assignments.
  • Responsible for complex and thorough investigation of appeals, external complaints, and fair hearing reviews, including:
    • Formulate action plan to ensure all activities are completed by the regulatory timeline
    • Gather all relevant information for the appeal request, such as external medical records and internal documentation
    • Evaluate gathered information to ensure accurate interpretation of benefit language and appropriate application of pharmacy and medical policies
    • Resolve appeal and fair hearing requests prior to committee or fair hearing review, when appropriate
    • Collaborate internally with various departments and externally with providers, agents, members, and employer groups
    • Coordinate and manage reviews with Independent Review Organizations (IRO) when necessary
    • Ensure all required documentation and files are complete, organized, and secure
  • Effectuate Appeal Committee and Department of Insurance and Financial Services (DIFS) directed decisions
  • Perform quality assurance reviews for case files, decision forms, documentation, and logs
  • Act as lead for expedited requests and ensure timely investigation, review, decision, and completion
  • Provide technical, product, policy, and procedure education and training for staff
  • Analyze and investigate requests for fair hearings, prepare comprehensive documentation for Administrative Law Judge
  • Facilitate Appeal Committee meetings
  • Track all activity and communication for each appeal case
  • Collaborate with cross-functional departments to implement improvements
  • Conduct root cause analysis to determine corrective actions
  • Apply strong analytical skills and business knowledge to investigation and recommendation of solutions
  • Communicate, collaborate, and act as a consultant to resolve complex issues
  • Required: Associate's Degree or equivalent
  • Preferred: Bachelor's Degree or equivalent
  • 5 years of relevant experience as a Grievance & Appeal Analyst or in a related role
  • Required: 3 years of relevant experience in Member or Provider Customer service, Claims, Legal, and/or enrollment/eligibility
  • Preferred: Working knowledge of Health systems for claims payment, care management, authorizations, customer service interactions, pharmacy, Rx profiles, medical policies, and plan documents for all non-Medicare product lines (Commercial Group, Commercial individual, PH Insurance Company (PHIC), Self-funded, Government Programs - Medicaid)
  • Preferred: Extensive knowledge of managed care products and regulatory and accreditation requirements

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