This position is responsible for researching, responding to, and seeing to full resolution all plan appeals and grievances, both medical and Part D within the Centers for Medicare & Medicaid Services (CMS) regulations.  Candidate must thoroughly investigate all appeals to understand the issue, coordinate input from other departments, apply plan guidelines, and reach an independently made plan decision.  Case must be responded to using CMS approved letters and appropriate action taken which may include helping to arrange for services coordinated with UM, process claims or prepare the case to go onto the Independent Review Entity.   Candidate will investigate all plan grievances, coordinate with outside parties in the case of delegated services, track and trend patterns and submit recommendations for plan consideration.

Candidate must closely monitor all appeals & grievances for timely resolution regardless of obstacles and follow CMS guidelines for extensions, when applicable.   

Qualifications Needed:

Candidate must have investigative skills and the ability to make decisions using their findings and judgment.  Candidate must be able to interpret CMS regulations and apply them correctly to the situation presented.  Candidate must be able to communicate clearly and effectively with both inside and external customers and departments.

Candidate must have working PC knowledge and excellent keyboarding skills.  Excellent decision making skills, multi tasking ability and good organizational skills along with working knowledge of Microsoft Word and Excel.  Candidate must have excellent written and verbal communication skills.  Knowledge of Federal & State Healthcare regulations, Essence benefits and how they are administered, P & P’s, Contracts etc.

Specific Responsibilities:

Handle all appeals and grievances within CMS guidelines to ensure plan compliance.

Ensure all action is taken before a case is closed.

Document all action for CMS review.

Participate in CMS site review process.

Maintain detailed and up to date desk procedures.

Educate staff on assisting members or non par providers in the appeals process or plan grievance process,  whichever is applicable.

Determine if and when an official Appeals committee should be formed and facilitate meetings.

We offer competitive salary and excellent benefits, Including 401k, EOE

 Please Apply at