GENERAL SUMMARY:

Responsible for the prompt and thorough investigation of medical, transportation, and pharmacy member appeals and grievances for Health Alliance Plan’s (HAP’s): Commercial, Medicare Advantage, Medicare-Medicaid Program (MMP), and Medicaid lines of business. Analyst must identify trending issues on an ongoing basis and provide root/cause analysis when required. The Analyst will work with HAP’s medical directors, nurses, pharmacists, Legal department, and other subject matter experts to determine appropriate outcomes for all cases. In addition, in this role the analyst will be required to keep abreast of regulatory requirements from State and Federal agencies and speak before members, senior leaders and other key stakeholders to present appeal cases on an ongoing basis. The analyst will also provide necessary support for audits and the development of desk level procedures.

PRINCIPLE DUTIES AND RESPONSIBILITIES:\

• Conduct the primary investigation and resolution of member appeals and grievances following established guidelines from: The Center for Medicaid and Medicare Services (CMS), MAXIMUS Federal Services, Department of Labor (DOL), Department of Insurance and Financial Services (DIFS), Michigan Department of Health and Human Services (MDHHS), National Committee for Quality Assurance (NCQA), Office of Personnel Management (OPM), MI Health Link, and Better Business Bureau (BBB).

• Demonstrate strict adherence to the Centers for Medicare and Medicaid (CMS), MI Health Link (MMP), and Michigan Department of Health and Human Services (MDHHS) contracts in the responses to members and regulatory agencies.

• Provide concise and thorough written responses to members and regulatory agencies regarding the findings of their investigations.

• Perform case pre-analysis, and procure appropriate medical records and supporting documentation prior to sending case to internal stakeholders for subject matter expert reviews.

• Prepare cases for presentation during pertinent hearings (e.g. Administrative Law Judge hearings, MAXIMUS Committee Meetings, State Fair Hearings, Second-Level Member Hearings).

  EDUCATION/EXPERIENCE REQUIRED:

• Associate degree in healthcare or a related field.

• At least two (2) years of member appeal and grievance experience .

• Minimum of two (2) years of experience working on utilization management platform-processing authorizations.

• Minimum of two (2) years of experience compiling data for appeal review with regulatory entities.

• Minimum of two (2) years of experience performing quality management case reviews.

• Must have successful experience with business writing which will be demonstrated by passing a writing assessment.

• Demonstrated knowledge of the Medicare Advantage, Federal Government, Medicare benefits, all Commercial including Self-Funded benefit guides, contracts and riders, eligibility and direct pay programs and rates.

• Demonstrated knowledge of billing/claims and customer service functions in a healthcare environment.

  SKILLS :

• Must demonstrate strong analytical and critical thinking skills.

• Must demonstrate excellent problem-solving techniques.

• Must possess a very high degree of patience, maturity, empathy, tact and diplomacy and be able to work with all levels of people within the organization.

• Must possess a high degree of poise and good judgment in responding to inquiries from customers with varying attitudes and have excellent written, listening and verbal communication skills.

• Must be flexible and handle multiple priorities through organizational and time management skills.

• A demonstrated ability to work in a Windows environment, HAP’s current documentation system (Pega A&G, Pega CRM and Microsoft Word).

• Knowledge of medical terminology.

  CERTIFICATIONS/LICENSURES REQUIRED:

• Minimum of two (2) years of experience as a Licensed Practical Nurse (LPN) in the State of Michigan preferred.

• Minimum of two (2) years of experience as a Registered Health Information Technician (RHIT) preferred.

Additional Information

• Organization: HAP (Health Alliance Plan)

• Department: Appeals and Grievances

• Shift: Day Job

• Union Code: Office/Non-Exempt, HAP

  Additional Details

  This posting represents the major duties, responsibilities, and authorities of this job, and is not intended to be a complete list of all tasks and functions. It should be understood, therefore, that incumbents may be asked to perform job-related duties beyond those explicitly described above.

Overview

Partnering with nearly 2 million people on their health journey, Henry Ford Health provides a full continuum of services at 250 care locations throughout southeast and south central Michigan. With 33,000 valued team members, Henry Ford is also among Michigan’s largest and most diverse employers. Our superior care and discoveries are powered by nearly 6,000 physicians, researchers and advanced practice providers. Learn more athenryford.com.

Benefits

Whether it's offering a new medical option, helping you make healthier lifestyle choices or making the employee enrollment selection experience easier, it's all about choice. Henry Ford Health has a new approach for its employee benefits program - My Choice Rewards. My Choice Rewards is a program as diverse as the people it serves. There are dozens of options for all of our employees including compensation, benefits, work/life balance and learning - options that enhance your career and add value to your personal life. As an employee you are provided access to Retirement Programs, an Employee Assistance Program (Henry Ford Enhanced), Tuition Reimbursement, Paid Time Off, Employee Health and Wellness, and a whole host of other benefits and services. Employee's classified as contingent status are not eligible for benefits.

Equal Employment Opportunity/Affirmative Action Employer

Equal Employment Opportunity / Affirmative Action Employer Henry Ford Health is committed to the hiring, advancement and fair treatment of all individuals without regard to race, color, creed, religion, age, sex, national origin, disability, veteran status, size, height, weight, marital status, family status, gender identity, sexual orientation, and genetic information, or any other protected status in accordance with applicable federal and state laws.