Appeals Specialist - JHP

Job Details

Job Description

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 Medicare Appeals Specialist is responsible for independently coordinating Part C & Part D Expedited, Pre-Service and Standard Appeals and Grievances. In addition to monitoring and responding to Complaints received through CMS' Complaint Tracking Module (CTM's) from receipt to resolution. The Specialist must have a broad knowledge of products and benefits as well as have an understanding of regulatory requirements and timeframes.

As the Appeals Specialist, your daily duties may include:

• Must have a thorough understanding of Health Plan operations and business unit processes, work flows and system requirements, including but not limited to, authorizations, billing, claims and regulatory compliance and plan benefits.
• Ensures the timely and accurate documentation, review, routing and tracking of member issues in compliance with regulations established by external regulating bodies and applicable state and federal laws.
• Handles multiple issues and prioritizes appropriately with the ability to organize work to meet deadlines.
• Conducts research by speaking with members and providers, reviewing member's records and benefit plan and obtaining responses from various business areas.
• Demonstrates ability to process complex information and deliver the information both verbally and written, in a professional, clear, concise and articulate manner.
• Requires excellent interpersonal skills in order to communicate and work with multiple constituents and be able to recognize sensitive issues and when to escalate to Management.
• Prepares case files for Independent Review Entities that are well organized, contain relevant documentation and are processed within the required timeframes.
• Maintains corporate policies and procedures and other formal documents pertinent to the complaint, grievance and appeal function.
• Be available to participate in the on-call process during weekends and holidays on a rotation basis.
• Other duties as assigned.

Qualifications

• Bachelor's degree, or Paralegal, with at least 3-5 years processing Medicare Part C & Part D Grievances and Appeals from receipt to resolution.

Skills, We Value:

• Strong communication (written/oral), and organization skills with great level of attention to detail
• Ability to interpret medical terminology, regulations/statutes and apply them without direct supervision
• Exceptional presentation skills
• Knowledge of Microsoft Office, CCMS, MACESS, and relational databases

Work Shift

Worker Sub Type

Primary Location Address

Nationally ranked, Jefferson, which is principally located in the greater Philadelphia region, Lehigh Valley and Northeastern Pennsylvania and southern New Jersey, is reimagining health care and higher education to create unparalleled value. Jefferson is more than 65,000 people strong, dedicated to providing the highest-quality, compassionate clinical care for patients; making our communities healthier and stronger; preparing tomorrow's professional leaders for 21st-century careers; and creating new knowledge through basic/programmatic, clinical and applied research. Thomas Jefferson University, home of Sidney Kimmel Medical College, Jefferson College of Nursing, and the Kanbar College of Design, Engineering and Commerce, dates back to 1824 and today comprises 10 colleges and three schools offering 200+ undergraduate and graduate programs to more than 8,300 students. Jefferson Health, nationally ranked as one of the top 15 not-for-profit health care systems in the country and the largest provider in the Philadelphia and Lehigh Valley areas, serves patients through millions of encounters each year at 32 hospitals campuses and more than 700 outpatient and urgent care locations throughout the region. Jefferson Health Plans is a not-for-profit managed health care organization providing a broad range of health coverage options in Pennsylvania and New Jersey for more than 35 years.

Jefferson is committed to providing equal educational and employment opportunities for all persons without regard to age, race, color, religion, creed, sexual orientation, gender, gender identity, marital status, pregnancy, national origin, ancestry, citizenship, military status, veteran status, handicap or disability or any other protected group or status.