The Medicare Appeals Supervisor is responsible for assisting the Senior Counsel of Appeals in all aspects of developing and maintaining a knowledgeable staff of Legal Researchers and Appeals Analysis who assist with the processing of Medicare Advantage Appeals. The Medicare Appeals Supervisor will also be responsible for assisting the Senior Counsel of Appeals with classification of correspondence received regarding Medicare Advantage enrollees as appeals, grievances, or contracting provider claim review requests and will provide instruction to Legal Researchers and Appeals Analysists in how to appropriately document, research, and respond to this correspondence.
EDUCATION
Bachelor’s degree in related field. In lieu of degree, five (5) years’ relevant experience will be considered.
EXPERIENCE
Minimum five (5) years' experience OR applicable Masters in related field with minimum three (3) years' experience.
Experience in Medicare Advantage or insurance appeals processing or related aspect of Medicare Advantage operations.
Demonstrated success as an individual contributor in current or related operational/functional area. Exhibits ability to coach and train others; possesses organizational and planning skills. May have team leader experience.
Extensive knowledge of benefits and CMS regulations for the Medicare Advantage line of business sold by Arkansas Blue Medicare and Health Advantage.Â
Understanding of Medicare Advantage claims processing, adjustments, claim procedures, the enrollment process, grievances, and other faucets of this line of business in order to review appeals and seek assistance from the appropriate areas of the Company and its vendors.
ESSENTIAL SKILLS & ABILITIES
Oral & Written Communication
Ability to explain complex issues in writing.
Ability to communicate in a grammatically correct and professional manner both orally and in writing.
Ability to utilize Microsoft Word and Excel.
Ability to understand medical terminology as it relates to the issues brought up in the appeal
Audits Medicare Advantage appeals files to ensure appropriate follow up, accuracy of information and correct use of grammar and punctuality., Demonstrates reliability in work attendance and job performance and use of appropriate discretion in maintaining confidentiality of all company information, including any sensitive proprietary or legal information., Develops and coordinates improvement processes and training opportunities Ability to make decisions, render judgments, take action and assume responsibility for those decisions., Handles telephone and email communications with Enrollees, providers, attorneys, and insurance regulators appropriately. , Maintains a close working relationship with contacts in customer service, claims, compliance, customer accounts, utilization management, the medical directors’., Obtains an understanding of procedures related to BlueCard Home and Host Processing, Home and Host Adjustments, BlueCard Association Licensee Requirement Manual, offices, government relations, etc., is imperative to collecting complete, accurate information for use in appeals resolution., Organizes workflow for maximum efficiency and effectiveness and to function independently in the absence of the Sr. Counsel of Appeals., Provides prompt responses to requests from other areas of the Enterprise for data related to their particular location or line of business.   , Provides quality review of appeal researchers work to ensure accuracy of content and to verify that appropriate procedures have been followed., Sorts data for quarterly and yearly reports for submission to management with appropriate documentation. Appropriate data will be presented in accepted qualify management format., Supervises the hiring, coaching/training, employee development and performance management of assigned team. , Utilizes information gained from processes to recommend improvements to department., Works with Sr. Counsel Appeals to ensure that all regulatory requirements of the complaint and appeal process have been met.
This position is identified as level three (3). This position must ensure the security and confidentiality of records and information to prevent substantial harm, embarrassment, inconvenience, or unfairness to any individual on whom information is maintained. The integrity of information must be maintained as outlined in the company Administrative Manual.
Segregation of duties will be used to ensure that errors or irregularities are prevented or detected on a timely basis by employees in the normal course of business. This position must adhere to the segregation of duties guidelines in the Administrative Manual.
Regular
ADA Requirements
1.1. General Office Worker, Sedentary, Campus Travel – Someone who normally works in an office setting or remotely and routinely travels for work within walking distance of the location of primary work assignment.Â
