Competitive Compensation & Benefits Package!
Position eligible for –
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Annual incentive bonus plan
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Medical, dental, and vision insurance with low deductible/low cost health plan
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Generous vacation and sick time accrual
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12 paid holidays
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State Retirement (pension plan)
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401(k) Plan with employer match
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Company paid life and disability insurance
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Wellness Programs
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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:
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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
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Assisting members/recipients, legal guardians and/or legal representatives in completing appeal requests for the agency
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Following federal, state and organizational policies
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Receive, track and follow individual authorization appeals from initiation to completion
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Work collaboratively with members/recipients/ legal guardian/legal representatives, providers, stakeholders, agency staff and others as necessary to ensure due process of authorization appeals
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Monitor the assignment of the local reconsideration review process for each appeal
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Timely documentation of all contacts with member/recipient/guardian, reviewer and providers; and establish and maintain the denial and appeals records
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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:
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Provide education, support and information to member/recipient, legal guardians, legal representatives and providers concerning and during the appeals process
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Answer questions about appeals process and assist member/recipient, legal guardians, and legal representatives in completing appeals forms (Medicaid & Non-Medicaid)
Liaison:
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Serves as a staff liaison for all member/recipient, legal guardians, legal representative, providers, community stakeholders and the agency staff regarding all adverse events
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Responds to questions regarding authorization appeals in a timely manner
Misc:
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Uses tact and diplomacy in communication with members/recipients, legal guardians, legal representatives, providers and others while working through the appeals process
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Effectively works with others to ensure timeliness of appeals process
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Appropriately responds to or directs questions/concerns and promotes a positive work environment.
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Participates in a telephone workgroup rotation to address calls received in the Appeals department.
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Other duties as assigned by Supervisor.
Knowledge, Skills and Abilities:
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Knowledge of Federal and State regulations on behavioral healthcare denials and appeals processes
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National Accreditation knowledge specific to organization
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Knowledge of medical records practices and recordkeeping practices, including electronic records and imaging/scanning processes
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Knowledge in preparation for legal proceedings including mediation, administrative law courts and other legal processes
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Knowledge of agency policies and procedures that pertain to duties
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Knowledge of DMA and Division contracts specific to organization
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Knowledge of service definitions and DMA clinical policy
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Proficiency in Microsoft Office products (Word, Excel, Outlook, PowerPoint, etc.)
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Ability to organize multiple tasks and priorities and to effectively manage numerous details
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Ability to effectively and accurately manage projects from start to finish
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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
