Medical Management Appeals Specialist – Case Management Division

  • Vantage Health Plan, Inc.
  • Monroe, LA, United States

Job Description

Vantage Health Plan, Inc ., we specialize in taking care of people: our members, our patients, and our employees. We offer competitive salaries and great benefits! Benefits include: Health, Dental, Life, Accidental Death and Dismemberment, Long Term Disability, Paid Time Off, and 401(k).

Job Summary:

The Medical Management Appeals Specialist in the Case Management Division is responsible for researching and preparing assigned appeals that have potential for secondary and external review.

Essential Duties & Responsibilities:

• Responsible for handling assigned appeals based on the following: All Member appeals for all lines of business. All Medicare provider appeals from non-contracted providers.

• Research and prepare all qualifying appeals for review. This includes the gathering and case formatting but is not limited to: Research of CMS and VHP policy for claim processing, covered benefits, allowed services, internal decision history, internal claim processing, member medical chart review, member eligibility, provider contracts and terms, call tracking history, prior claim history. Thorough understanding of VHP structure and process flow to ensure key subject matter experts are involved in case preparation when necessary.

• File requests for Waivers of Liability or Appointment of Representative forms and requests for member medical records as applicable.

• Forward appeals for decision review by the clinical nurse specialist or Medical Directors based on defined criteria.

• Prepare case files and submit qualifying appeals through secondary and external review channels based on time critical governmental standards. This includes submission to the Medicare contracted external review entity and Louisiana Department of Insurance as applicable.

• Respond to any requests for additional information or consultation on appeals submitted to other departments and/or the Medical Directors.

• Prepare appeal determination notification letters as applicable.

• Correspond and communicate with independent review organization, providers, and members or members’ representatives as needed during appeal processing.

• Properly document, track and process all appeals through the internal VHP systems including the Appeals Module, Call Tracking, Claim Center, and Vtasks.

• Maintain records of cases for audit and governmental request, historical and training review, and reference guides for future cases.

• Assist other departments with collection of information, reporting, and specific review as requested.

Marginal Duties

Other duties as assigned.

Job Requirements:

Knowledge, Skills, and Abilities: 

• Bachelor’s Degree or one to three years of experience in appeals processing or related field.

• Knowledge in areas of appeal processing, including but not limited to Appeal Case Preparation and Management, Claims Processing, Coding and Billing, Medicare and governmental regulations, and VHP policy and procedures.  

• Ability to write clearly and informatively. Edits work for spelling and grammar. Presents numerical data effectively and able to read and interpret written information.

• Ability to construct sound, compelling factual arguments.

• Problem analysis and problem resolution at both a strategic and functional level.

• Ability to organize and manage multiple priorities. Demonstrates accuracy and thoroughness. Looks for ways to improve and promote quality and monitors own work to ensure quality.

• Customer service-oriented attitude/behavior.

• Ability to work with limited supervision and to make decisions based on established policies and procedures.

• Ability to think ahead and plan over a multi-year time span.

• Ability to interact effectively with all staff at all levels of management.

• Ability to work under stress.

Supervisory Responsibilities

• None.

Supervision Received 

• Works under direct supervision of Appeal Supervisor and occasional direction of Medical Management Medical Directors.

Working Conditions

Overtime may be occasionally required.  

Physical Demands 

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. 

While performing the duties of this job, the employee is regularly required to sit, use hands and fingers, handle or feel, reach with hands and arms, and talk or hear. The employee is frequently required to stand and walk. The employee must regularly lift and/or move up to 10 pounds and frequently lift and/or move up to 25 pounds. 

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