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Priority Health · 12 hours ago

Medicare Non Contracted Provider Appeals Analyst

Grand Rapids, MI

Full-time

Onsite

Senior Level

5+ years exp

Priority Health is a health plan that is seeking a Medicare Non Contracted Provider Appeals Analyst to support non-contracted provider post claim appeals. The role involves analyzing, researching, and completing complex member appeal investigations while ensuring compliance with regulatory requirements and providing education to internal departments.

Health Care

Responsibilities

Responsible for complex and thorough investigation of appeals, external complaints, and fair hearing reviews including: formulate action plan to ensure all activities are completed by the regulatory time line, gather all relevant information for the appeal request (external medical records, internal documentation from enterprise-wide systems including: claims payments, billing and enrollment, care management, medical, pharmacy and behavioral health authorizations, customer service interactions, prescription claims, medical policies, and plan documents). Evaluate information gathered to ensure all benefit language outlined in plan documents have been interpreted accurately and consistently, determine if pharmacy and medical policies have been applied appropriately or if additional clinical information is available after the original decision

Resolve appeal and fair hearing requests prior to committee or fair hearing review, when appropriate, including collaboration internally with all levels within the organization including Executives, Market Segment Leaders, Medical Directors, Legal, Medical Operations, Enterprise Operations, Customer Service, and leaders throughout the organization and externally with providers, agents, members, and employer groups. If not resolved prior to the Appeal Committee process, prepare the presentation of all relevant facts and present concise yet comprehensive information to the appropriate committee(s) to ensure a full and fair review; Coordinate and manage reviews with Independent Review Organizations (IRO) when appropriate; work with Medical Directors to suggest and solicit appropriate questions for IRO response. Ensure all required documentation and files are complete, organized and secure to meet State, Federal, Health Plan and NCQA requirements. Effectuate Appeal Committee and Department of Insurance and Financial Services (DIFs) directed decisions and ensure outcomes are effectively communicated (oral and written) following regulatory and NCQA requirements

Perform quality assurance reviews for case files, decision forms, documentation and logs to ensure they are complete, organized and secure and ensure all procedures are followed and time line requirements are met, including implementation of all Committee, and State or Federal decisions

Act as lead for expedited requests, gathering relevant information, working with Medical Director to determine if criteria is met. If expedited criteria is met, ensure investigation, review, decision, and completion within required 72 hour time line. Communicate outcome to member

Provide technical, product, policy and procedure education and training for new and existing staff. Provide education and communicates training needs to Customer Service Leadership, when appropriate, to avoid unnecessary appeals and/or expedited requests

Analyze and investigate requests for fair hearings; gather relevant information and prepare comprehensive documentation as “evidence” for the State of Michigan Administrative Law Judge. Ensure timely submission of documentation prior to the scheduled hearing. Represent Priority Health during the fair hearing process with the member and/or member’s representative (i.e. attorney, physician, agent) and the State of Michigan Administrative Law Judge. Present facts and legal evidence in a comprehensive and professional manner to demonstrate the rationale for the Priority Health decision in order for the State of Michigan Judge to make a final determination

Facilitate Appeal Committee meetings to ensure full and fair review. Track all activity including communication for each appeal case by entering complete documentation of issues and related follow-up, ensuring all customers receive required correspondence according to time line requirements and to ensure all regulatory reporting requirements are met

Collaborate with cross-functional departments to implement improvements to member experience, medical policies, legal documents, member materials, departmental processes and workflow. Conducts root cause analysis to determine corrective actions related to the appeals process by researching systemic issues to determine course corrections Apply strong analytical skills and business knowledge to investigation, analysis and recommendation of solution Communicates, collaborates and acts as a consultant to internal and external customers in order to resolve complex issues

Qualification

Grievance & Appeal AnalysisRegulatory ComplianceManaged Care KnowledgeAnalytical SkillsCustomer ServiceTraining & MentoringCollaboration

Required

Associate's Degree or equivalent

5 years of relevant experience Grievance & or Appeal Analyst or related experience

Preferred

Bachelor's Degree or equivalent

3 years of relevant experience Member or Provider Customer service, Claims, Legal and/or enrollment/eligibility

Working knowledge of Priority Health systems for claims payment, care management, authorizations, customer service interactions, pharmacy, Rx profiles, medical policies, and plan documents for all non-Medicare product lines (Commercial Group, Commercial individual, PH Insurance Company (PHIC), Self-funded, Government Programs – Medicaid)

Extensive knowledge of managed care products and regulatory and accreditation requirements; Maintain knowledge of policies and procedures, including medical policies which may impact the grievance, appeal and review processes