Purpose/belief statement:

The position of Appeal Analyst as part of the Health Plan Operations Team reports directly to Director of Operations with strong collaborative relationships with Provider Relations and Contracting, Clinical staff, the CMO, and the vendors to ensure adhesion to Health Plan expectations and CMS regulations.

Job duties & responsibilities

• Manage end-to-end appeals process

• Review and resolve member and provider appeals which includes communicating the decision to members, authorized representatives, and providers

• Resolve issues in accordance with standards, timeframes and other requirements of the Health Plan and CMS

• Prepare the written communication of the decision in language that is easily understood by the member or their responsible party

• Maintain appeal documentation and tracking within the appropriate tracking system. Maintain electronic files of all documentation and appropriate follow up documentation and resolution within the system

• Elevate appeals to the Clinical Quality Manager or CMO as appropriate and necessary

• Prepare and submit files to the Independent Review Organization (IRO) when required by CMS

• Develop working relationships with internal partners and key vendors

• Prepare G&A reporting on monthly or quarterly basis for CMS and Health Plan leadership

• Develop workflows for G&A process, update internal policies and procedures as necessary

• Analyze claim denials and determine if claims are processing correctly in accordance with CMS requirements and in accordance with the provider contract

• Research Medicare claim processing guidelines when necessary

Qualifications & Experience requirements

• Healthcare claim processing experience

• Claim and pre-service appeal experience preferred

• Bachelor’s degree in business, health care administration, or similar; or at least 2 years of experience working in health care or health insurance field

• 2 years of experience with government health insurance (Medicare, Medicare Advantage, Medicaid) preferred

• Excellent communication skills, both verbal and written

• Exceptional phone etiquette

• Exceptional attention to detail and ability to meet all required deadlines

• Ability to multi-task and adapt to changing priorities

• Proficient typing skills, ability to work in Office applications and program software programs

Knowledge/Skills/Abilities

• Must have integrity and a strong ethical compass.

• Must be flexible, able to work independently, and able to achieve deadlines and deliverables with minimal supervision.

• Must be excited by the opportunity to work within an integrated delivery system.

• Must have strong communication skills and ability to work effectively with people coming from diverse cultural and professional perspectives.

Benefits

As a CommuniCare employee you will enjoy competitive wages and PTO plans. We offer full time employees a menu of benefit options from life and disability plans to medical, dental, and vision coverage from quality benefit carriers. We also offer 401(k) with employer match and Flexible Spending Accounts.

About Us

A family-owned company, we have grown to become one of the nation’s largest providers of post-acute care, which includes skilled nursing rehabilitation centers, long-term care centers, assisted living communities, independent rehabilitation centers, and long-term acute care hospitals (LTACH). Since 1984, we have provided superior, comprehensive management services for the development and management of adult living communities. We have a single job description at CommuniCare, "to reach out with our hearts and touch the hearts of others." Through this effort, we create "Caring Communities" where staff, residents, clients, and family members care for and about one another.