Appeals Specialist

Why Choose Jefferson Health Plans?

We are an award-winning, not-for-profit health maintenance organization offering Medicaid, Medicare, and Children’s Health Insurance Program (CHIP) plans that include special benefits to improve the health and wellness of our members. We are committed to creating a community where everyone belongs, acknowledges, and celebrates diversity and has opportunities to grow to their fullest potential.

While this job currently provides a flexible remote option, due to in-office meetings, training as required, or other business needs, our employees are to be residents of PA or the nearby states of DE or NJ.

Perks of JHP and why you will love it here:

• Competitive Compensation Packages, including 401(k) Savings Plan with Company Match and Profit Sharing 
• Flextime and Work-at-Home Options
• Benefits & Wellness Program including generous Time Off 
• Impact on the communities we service 

We are seeking a talented and enthusiastic Appeals Specialist to join our team!

The Appeals Specialist is responsible for independently coordinating Medicaid, CHIP and ACA Standard and Expedited Complaints and Grievances from receipt to resolution. The Appeals Specialist must have a broad knowledge of products and benefits as well as understand regulatory requirements and timeframes.

As the Appeals Specialist, your daily duties may include: 

• Able to work in a constant state of alertness and safe manner
• Keeps current with all rules, regulations, policies, and procedures relevant to the Complaints, Grievances, and Appeals Unit.
• Manages case load including standard and expedited cases, multiple systems, and plans appropriate allocation of resources to provide quality assessment of assigned complaints and grievances.
• Develops and maintains collaborative relationships with internal and external customers.
• Perform outreach calls to members, head of household, and authorized representatives.
• Ensures the timely and accurate review, routing, and tracking of member complaint and grievance issues in compliance with Medicaid and CHIP requirements.
• Identifies and analyzes various member issues/concerns, and ensures well documented resolution(s) of the same.
• Interpret member benefit limit exceptions and denial information in order to clearly communicate and manage expectations.
• Outreaches to provider offices to obtain responses to member complaints involving primary care physicians, specialists, hospitals, ancillary services/durable medical equipment, delegated vendors, and their staff.
• Oversees timely resolution of and response to member and provider issues in conjunction with Quality Management, Pharmacy, Utilization Management, and other HPP departments/sub-contractors.
• Reviews and interprets Health Care Management case notes, medical records and pharmacy profiles and draft comprehensive case summaries to forward to external and internal physicians and pharmacists for reviews and to present to committee members for hearings.
• Drafts well-written acknowledgment, review notification, and decision letters timely in response to member complaints and grievances.
• Facilitates written and verbal communication of and scheduling/preparation for 1^st and 2^nd Level member complaint committees and grievance hearings.
• Prepares and presents complaints and grievances to the Complaint and Grievance Committee in accordance with Health Choices Agreements, CHIP Handbook and ACA requirements.
• Prepares cases for 3^rd level external reviews to the Department of Health or to a Certified Review Entity and ensure they are submitted timely.
• Maintains corporate policies and procedures and other formal documents pertinent to the complaint, grievance, and appeal function/option in conjunction with either the Department of Health and or Pennsylvania Insurance Department.
• Assists with Triage Specialist responsibilities as needed.
• Performs special projects as assigned by management.
• Perform other duties as assigned.

Qualifications

• Bachelor’s degree preferred and/or 4 years experience in managed care with a concentration in compliance, legal, or quality management.

 Skills, We Value:

• Outstanding written and oral communication skills. 
• Excellent negotiation and analytical skills.
• Exceptional presentation skills.
• Knowledge of Microsoft Office, Health Rules Payor, Salesforce, Health Rules Care Manager, and relational databases.