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
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
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 USFHP 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
- 3+ 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
We are an equal opportunity/affirmative action employer.
Do you have a question about careers at Martin’s Point Health Care? Contact us at: jobinquiries@martinspoint.org
