Summary of PositionResponsible for processing expedited appeals: those that are complex in nature, require multiple hand-offs, and tend to have extremely tight deadlines. Ensure accuracy and compliance within the constraints of extremely quick turnaround times. Perform end-to-end G&A processing; consistently operate in a fast-paced high-pressure environment. Monitor all aspects of the G&A process; ensure that members have appropriate access to care. Due to regulatory requirements and turn-around times of the Expedited Appeal unit, the Specialists are required to work weekends and holidays as the organization must maintain expedited appeal coverage 7 days a week, 365 days a year. Responsibilities:
- Independently perform triage function: review and evaluate appeal requests; identify and classify member and provider appeals. Using internal systems, determine eligibility, benefits, and prior activity related to the claims, payment, or service in question.
- Provide verbal and written member and provider correspondence as needed for authorized representative or needed clinical information.
- Conduct thorough investigations of all member and provider correspondence by analyzing all the issues presented and obtaining responses and information from internal and external entities. Validate the responses to ensure they address the issues and are supported by any contract stipulations, regulations, etc., as applicable.
- Make critical decisions regarding research and investigation to appropriately resolve all inquiries; prepare cases for medical and administrative review detailing the findings of their investigation for consideration in the Plan's determination; make recommendations on administrative decisions by preparing detailed case summaries and reviewing all applicable benefit and contract materials; present findings and recommendations to appropriate parties for sign-off.
- Serve as liaison with EmblemHealth departments, delegated entities, medical groups, and network physicians to ensure timely authorization effectuation and resolution of cases.
- Perform necessary follow-up with responsible departments and delegated entities to ensure compliance.
- Monitor hourly and daily pending reports and personal worklists, ensuring adherence to CMS, NCQA, DOH, NYS, Connecticut and Massachusetts regulatory requirements, as well as operational SLAs and department performance standards, thereby ensuring members' access to care.
- Independently prepare well written, customized responses to all correspondence that appropriately and completely address the complainant's issue(s) and are structurally accurate. Responsible for ensuring responses are completed within the applicable regulatory timeframe.
- Complete submission of case files and responses to entities such as DFS, DOH, AG and Maximus; ensure timely and appropriate response submissions.
- Document final resolutions along with all required data to facilitate accurate reporting, tracking, and trending.
- Identify workflow improvements and work with the team to recommend and implement change(s).
- Provide recommendations to management regarding issue resolution, root cause analysis and best practices.
- Serve as a point of escalation for problems, providing guidance and expertise to team members as well as helping to identify and address core business requirements.
- May train, guide, and mentor new G&A Specialists.
- Serve as a coach and mentor to the associates providing support and guidance in complex situations.
- Maintain acceptable attendance standard with minimal unscheduled PTO.
- Exceed median production and compliance standards for both case resolution and data requirements.
- Perform other duties as directed, assigned, or required.
Qualifications:
- Bachelors' degree
- 3 - 5+ years of related experience, preferably in the health industry and/or area of compliance required
- Additional related experience/specialized training may be considered in lieu of degree requirements required
- Extensive knowledge and experience in claims, enrollment, benefits, and member contracts required
- Ability to mentor specialists and to provide assistance on complex cases required
- Must be well versed in all aspects of the complaint, grievance and appeal process and be able to process all types of correspondence handled by Grievance and Appeals required
- Proficiency in MS Office (Word, Excel, PowerPoint, Outlook, Teams, SharePoint, etc.) required
- Excellent product knowledge required
- Excellent prioritizing, organizing, time management, problem solving and analytical skills required
- Ability to work under pressure and deliver complete, accurate, and timely results required
- Leadership skills preferred