Job Summary

Job Description

• Review, analyze, and investigate assigned appeals to determine if the proposed action taken by field staff was accurate based on policy, procedure, and information found within the various Medicaid systems.
• Draft and assemble the following documents: appeals cover memoranda; summaries of evidence; agency reversals which will include e-mails to staff notifying that a corrective action needs to be taken and letters to the appellants explaining the action taken; withdrawals; and untimely request documents.
• Forward the Summary of Evidence, reversal or withdrawal to assigned reviewer, make edits recommended by reviewer.
• Upload appeals documents into Medicaid’s Electronic Case Record and upload the documents to the Division of Administrative Law/LDH SharePoint site. Notate the Case Notes indicating that the uploading has been completed and notify the Centralized Appeals Unit's representative assigned to track the appeal that the necessary documents have been uploaded and mailed to the appellant where applicable.
• Monitor the reviewed cases for corrective actions taken by field staff. Determine if all required corrective actions have been taken and email the field staff if further corrective actions are required.
• Mail a copy of the Summary of Evidence to the appellant or, if applicable, ensure that a copy of the reversal is mailed to the appellant, and notify the Centralized Appeals Unit's representative assigned to track the appeal that it has been mailed and notate same in the Electronic Case Record.
• Review changes to Medicaid policy and procedures and attend meetings with Medicaid staff as necessary.
• Attend telephone and in person hearings, and cover hearings for employees who are not able to attend.
• Maintain knowledge of all Medicaid policies and procedures, and ensure that any new changes, updates and/or clearances are applied accordingly.
• Other tasks as directed.

QUALIFICATIONS

REQUIRED:

• Bachelor's degree, or an Associate's degree plus three years of professional experience, or six years of professional experience in lieu of degree.
• Excellent analytical skills, effective organizational and time management skills
• Great attention to detail and follow up, and verbal/written communications skills.
• Works well both independently and as part of a team.
• Ability to set, follow, and meet deadlines.
• Proficient in the use of Adobe Acrobat Pro as well as Microsoft Office Suite (Word, Excel, PowerPoint, and Outlook).

DESIRED:

• Advanced degree.
• Minimum one year of professional experience with Medicaid appeals processes and procedures.
• Minimum one year professional experience with Medicaid eligibility including MAGI, Non-MAGI, Long Term Care and HCBW programs.
• Minimum one year of professional experience working in the Medicaid eligibility system LaMEDS.
• Industry-related certifications such as HIM, RHIA, RHIT, CDI, CHDA.