Medicare Appeals Specialist

Job ID: J133551
Company: Highmark Inc
Location: Pittsburgh, PA, United States
Full/Part Time: Part time
Job Type: Regular
Posted at: Oct 31, 2018

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Description

General Overview:

The job conducts and documents thorough investigations of Part C, Part D, QIO and Administrative Law Judge Case Types, communicating resolution to members in accordance with Center for Medicare and Medicaid Services (CMS) requirements. Requires broad knowledge of plan products, medical policy requirements, processes and enrollment rules. Responsible for all aspects of Part C and D clinical appeals , up to and including decision making, considering potential impacts to regulatory compliance as well as CMS star ratings. Provides support to non-clinical appeals and ensures correct authorization of services.

Essential Responsibilities:

  • Complete and document thorough clinical investigation of all Part C, Part D, QIO Home Health and ALJ appeals. Perform research, request and review all related relevant documentation and assemble case file. Ensure accurate documentation of cases in the appeals management system, maintaining compliance with CMS reporting and data validation requirements. Ensure effective and compliant effectuation of appeals.
  • Review outcome of appeal, either independently or in conjunction with medical director.  Communicate effectively with members, providers,  and colleagues, successfully articulating issues, problems and solutions. 
  • Recommend process efficiencies, strategies for improvement and/or solutions to align with business strategies.  
  • Participate in process improvement meetings and/or discussions, recommending process efficiencies and/or strategies
  • for improvement.
  • Ensure quality assurance of appeal work, assist in development of desktop procedures and/or training materials.
  • Other duties as assigned or requested.

Required

  • High School/GED
  • 3 years Clinical Nursing
  • PA RN License
  • WV RN License (within 3 months after hire)

Preferred

  • Bachelor's in Nursing
  • 3 years Appeals Review
  • 3 years Utilization Management Review
  • 3 years Regulatory Compliance

Knowledge, Skills & Abilities:

  • Critical Thinking
  • Organization
  • Time Management
  • Decision Making
  • Written Communication
  • Cross-Functional Collaboration
  • Microsoft Word

Referral Bonus Level: 1

Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities, and prohibit discrimination against all individuals based on their race, color, religion, sex, national origin, sexual orientation/gender identity or any other category protected by applicable federal, state or local law. Highmark Health and its affiliates take affirmative action to employ and advance in employment individuals without regard to race, color, religion, sex, national origin, sexual orientation/gender identity, protected veteran status or disability.
EEO is The Law
Equal Opportunity Employer Minorities/Women/ProtectedVeterans/Disabled/Sexual Orientation/Gender Identity (http://www1.eeoc.gov/employers/upload/eeoc_self_print_poster.pdf)
We endeavor to make this site accessible to any and all users. If you would like to contact us regarding the accessibility of our website or need assistance completing the application process, please contact number below.
For accommodation requests, please call HR Services at 844-242-HR4U or visit HR Services Online at HRServices@highmarkhealth.org

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