Non-Contracted Provider Claims Appeals, Lead

Alignment Health is breaking the mold in conventional health care, committed to serving seniors and those who need it most: the chronically ill and frail. It takes an entire team of passionate and caring people, united in our mission to put the senior first. We have built a team of talented and experienced people who are passionate about transforming the lives of the seniors we serve. In this fast-growing company, you will find ample room for growth and innovation alongside the Alignment Health community. Working at Alignment Health provides an opportunity to do work that really matters, not only changing lives but saving them. Together.

The Non-Contracted Provider Claim Appeals Lead assists the management in the day-to-day operations of Non-Contracted Provider Dispute and Appeals unit within the Appeals & Grievance Department. The Lead shall serve as the subject matter expert for all related non-contracted providers, claim disputes and appeals including supporting Management. The Lead will conduct audits and training as assigned.

Job Duties/Responsibilities:
1.    Possess the knowledge in procedures, protocols, necessary information to resolve provider claim disputes and appeals; serve as a “subject matter expert” to support the team with day-today questions, monitoring, training, etc.,
2.    Assists in monitoring inventory and workloads which include but are not limited to provider disputes and appeals assignment, special projects, member services and provider inquiry and requests.
3.    Conducts audits and training assigned, collaborates with QA to identify root cause of denials or payment variance, including but are not limited to opportunities to improve quality and efficiency. Supports department initiatives in process improvement.
4.    Assumes a ‘working’ role assisting with processing provider disputes and provider appeals according to CMS, contractual and departmental guidelines.
5.    Corresponds with delegated entity as needed to obtain appropriate records or payment information. Follow through and ensure requested information is obtained.
6.    Produces written correspondence to resolve provider appeals and disputes. Ensure communications contain rationale which supports the determination or resolution of provider appeals or provider disputes.
7.    Prepares appropriate documentation and submit it to IRE when provider appeals result in adverse determination and/or untimely. Ensure IRE responses requiring effectuation are processed timely and accurately.
8.    Runs and monitors various reports which include but are not limited to CMS required reporting (Part C, ODAG reports for reconsideration and dismissals, etc.) and other departmental reports ensuring productivity, quality, and compliance standards are met.
9.    Participates in CMS and other health plan audits related to provider dispute and provider appeals.
10.    Performs additional related duties as assigned.

Job Requirements:

Experience:

• Required: Minimum 5 years’ experience processing Medicare Advantage provider disputes and appeals from all types of providers (hospitals, physicians, ancillary). 5 years’ experience in examining all types of medical claims, preferably Medicare Advantage claims.

• Preferred: 1 years’ experience in a Lead Role either in claims or provider dispute departments and

Education:

• Required: High School Diploma or GED.

• Preferred: Associate degree in related field, preferred.

Training:

• Preferred: Medical Terminology courses. Medical Coding courses

Specialized Skills:

• Required:

• Understanding of Medicare Advantage Provider appeals and dispute process
• Working knowledge of claims processing systems (EZCAP preferred).
• Working knowledge of medical terminology, standard coding and reference publications, CPT, HCPC, ICD-9, ICD-10, DRG, etc.
• Understanding of different payment methodology such as Medicare PPS (MS-DRG, APC, etc.), Medicare Physicians fee schedule, Per Diem, etc.,
• Understanding of Division of Financial Responsibility on how they apply to claims processing.
• Familiarity with billing and coding edits, coordination of benefits
• Proven problem-solving skills and ability to translate knowledge to the department.
• Working knowledge of Microsoft Office Programs (Outlook, Excel, and Word)
• Ability to use 10 keys.
• Ability to communicate positively, professionally and effectively with others; provide leadership, teach and collaborate with others.
• Effective written and oral communication skills; ability to establish and maintain a constructive relationship with diverse members, management, employees and vendors;
• Mathematical Skills:  Ability to perform mathematical calculations and calculate simple statistics correctly
• Reasoning Skills:  Ability to prioritize multiple tasks; advanced problem-solving; ability to use advanced reasoning to define problems, collect data, establish facts, draw valid conclusions, and design, implement and manage appropriate resolution.
• Problem-Solving Skills:  Effective problem solving, organizational and time management skills and ability to work in a fast-paced environment.
• Report Analysis Skills:  Comprehend and analyze statistical reports.

Licensure:

• Required: None

Work Environment

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job.  Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.

Essential Physical Functions:

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.

1.  While performing the duties of this job, the employee is regularly required to talk or hear. The employee regularly is required to stand, walk, sit, use hand to finger, handle or feel objects, tools, or controls; and reach with hands and arms.

2. The employee frequently lifts and/or moves up to 10 pounds. Specific vision abilities required by this job include close vision and the ability to adjust focus.

Pay Range: $64,384.00 - $96,577.00

Alignment Health is an Equal Opportunity/Affirmative Action Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, age, protected veteran status, gender identity, or sexual orientation.

*DISCLAIMER: Please beware of recruitment phishing scams affecting Alignment Health and other employers where individuals receive fraudulent employment-related offers in exchange for money or other sensitive personal information. Please be advised that Alignment Health and its subsidiaries will never ask you for a credit card, send you a check, or ask you for any type of payment as part of consideration for employment with our company. If you feel that you have been the victim of a scam such as this, please report the incident to the Federal Trade Commission at https://reportfraud.ftc.gov/#/. If you would like to verify the legitimacy of an email sent by or on behalf of Alignment Health’s talent acquisition team, please email careers@ahcusa.com.

Salary : $64,384 - $96,577