Competitive Compensation & Benefits Package!
Position eligible for –
- Annual incentive bonus plan
- Medical, dental, and vision insurance with low deductible/low cost health plan
- Generous vacation and sick time accrual
- 12 paid holidays
- State Retirement (pension plan)
- 401(k) Plan with employer match
- Company paid life and disability insurance
- Wellness Programs
See attachment for additional details.
Office Location: Gastonia, NC (Hybrid - will need to come into the Gastonia office a minimum of 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:
- Preparing, proofreading and verifying the accuracy of the LME/MCO notification letters to consumers/legal guardian/legal representatives and providers of reductions, suspensions, terminations or denials of services
- Assisting consumers, legal guardians and/or legal representatives in completing appeal requests for the agency
- Following federal, state and organizational policies
- Receive, track and follow individual authorization appeals from initiation to completion
- Work collaboratively with consumers/ legal guardian/legal representatives, providers, stakeholders, agency staff and others as necessary to ensure due process of authorization appeals
- Monitor the assignment of the local reconsideration review process for each appeal
- Document all contacts with consumer/guardian, reviewer and providers; and establish and maintain the denial and appeals records
- 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:
- Provide education, support and information to consumers, legal guardians, legal representatives and providers concerning and during the appeals process
- Answer questions about appeals process and assist consumer, legal guardians, and legal representatives in completing appeals forms (Medicaid & Non-Medicaid)
Liaison:
- Serves as a staff liaison for all consumers, legal guardians, legal representative, providers, community stakeholders and the agency staff regarding all adverse events
- Responds to questions regarding authorization appeals in a timely manner
Misc:
- Uses tact and diplomacy in communication with consumers, legal guardians, legal representatives, providers and others while working through the appeals process
- Effectively works with other to ensure timeliness of appeals process
Knowledge, Skills and Abilities:
- Knowledge of Federal and State regulations on behavioral healthcare denials and appeals processes
- National Accreditation knowledge specific to organization
- Knowledge of medical records practices and recordkeeping practices, including electronic records and imaging/scanning processes
- Knowledge in preparation for legal proceedings including mediation, administrative law courts and other legal processes
- Knowledge of agency policies and procedures that pertain to duties
- Knowledge of DMA and Division contracts specific to organization
- Knowledge of service definitions and DMA clinical policy
- Proficiency in Microsoft Office products (Word, Excel, Outlook, PowerPoint, etc.)
- Ability to organize multiple tasks and priorities and to effectively manage numerous details
- Ability to effectively and accurately manage projects from start to finish
- Ability to understand and adhere to amendments and priorities at the State, Federal, Accreditation or contract level
Education/Experience Required:
Bachelor’s Degree and two (2) years of Human Services/healthcare experience. An equivalent combination of education and experience may be accepted.
Education/Experience Preferred:
Master’s Degree and two (2) years of Human Services/healthcare experience.