Position eligible for – 

• Annual incentive bonus plan
• Medical, dental, and vision insurance with low deductible/low cost health plan
• Generous vacation and sick time accrual
• 12 paid holidays
• State Retirement (pension plan)
• 401(k) Plan with employer match
• Company paid life and disability insurance
• Wellness Programs

See attachment for additional details. 

Office Location: Gastonia, NC; Hybrid option available

Projected Hiring Range: Depending on ExperienceClosing Date: Open Until Filled

Primary Purpose of Position:This position is responsible for implementing and supporting the Tailored Plan Medicaid, Medicaid Direct and Non-Medicaid Appeals processes.  

Role and Responsibilities: 

Implementation of Tailored Plan Medicaid, Medicaid Direct and Non-Medicaid Appeals processes:  

• Preparing, proofreading and verifying the accuracy of the LME/MCO notification letters to consumers/legal guardian/legal representatives and providers of reductions, suspensions, terminations or denials of services
• Assisting consumers, legal guardians and/or legal representatives in completing appeal requests for the agency
• Following federal, state and organizational policies
• Receive, track and follow individual authorization appeals from initiation to completion
• Work collaboratively with consumers/legal guardian/legal representatives, providers, stakeholders, agency staff and others as necessary to ensure due process of authorization appeals
• Monitor the assignment of the local reconsideration review process for each appeal
• Document all contacts with consumer/guardian, reviewer and providers; and establish and maintain the denial and appeals records
• Gather, review, interpret and summarize documentation and additional information submitted in preparation for assignment of Local Reconsideration appeal to Peer Reviewer
• Utilize clinical knowledge of administrative codes, laws, statutes and LME/MCO/Tailored Plan administrative regulations to assist in the development and the revision of policies and procedures related to the appeals process.
• Additional duties as needed to support and/or provide oversight of the appeals process in clinical operations and other organizational departments as deemed applicable

Educate: 

• Provide education, support and information to consumers, legal guardians, legal representatives and providers concerning and during the appeals process
• Answer questions about appeals process and assist consumer, legal guardians, and legal representatives in completing appeals forms (Medicaid & Non-Medicaid)

Liaison:

• Serves as a staff liaison for all consumers, legal guardians, legal representative, providers, community stakeholders and the agency staff regarding all adverse events
• Responds to questions regarding authorization appeals in a timely manner
• Complete duties to aid the General Counsel & Chief Legal Officer as well as any LME/MCO contracted legal representatives in preparation for appeals related cases. Duties may include: Aid counsel in ensuring fluent communication and exchange of documents are effectively made between all parties involved in appeals process. Responsible for file review, file preparation and ensuring LME/MCO members have documentation and are prepared for mediation and hearings. Assists in the discovery process.

Misc:

• Uses tact and diplomacy in communication with consumers, legal guardians, legal representatives, providers and others while working through the appeals process
• Effectively works with other to ensure timeliness of appeals process

Knowledge, Skills and Abilities:

• Knowledge of Federal and State regulations on physical and behavioral healthcare denials and appeals processes
• National Accreditation knowledge specific to organization
• Knowledge of medical records practices and recordkeeping practices, including electronic records and imaging/scanning processes
• Knowledge in preparation for legal proceedings including mediation, administrative law courts and other legal processes
• Knowledge of agency policies and procedures that pertain to duties
• Knowledge of DMA and Division contracts specific to organization
• Knowledge of service definitions and DMA clinical policy
• Proficiency in Microsoft Office products (Word, Excel, Outlook, PowerPoint, etc.)
• Ability to organize multiple tasks and priorities and to effectively manage numerous details
• Ability to effectively and accurately manage projects from start to finish
• Ability to understand and adhere to amendments and priorities at the State, Federal, Accreditation or contract level

Education and Experience Required: Licensed to practice as a Registered Nurse in North Carolina with at least two years of clinical experience in a healthcare setting or a managed care setting. 

Education and Experience Preferred:Licensed to practice as a Registered Nurse in North Carolina, two years of clinical experience in nursing, experience with BH/IDD/TBI population and Managed Care and/or Utilization Management appeals experience.

Licensure/Certification Requirements: Must be licensed as a Registered Nurse in North Carolina. Employee is responsible for complying with respective licensure board’s continuing education/training requirements in order to maintain an active license.