Temporary Appeals Specialist I

at Martin's Point Health Care in Portland, Maine, United States

Job Description

Join Martin’s Point Health Care – an innovative, not-for-profit health care organization offering care and coverage to the people of Maine and beyond. As a joined force of “people caring for people,” Martin’s Point employees are on a mission to transform our health care system while creating a healthier community. Martin’s Point employees enjoy an organizational culture of trust and respect, where our values – taking care of ourselves and others, continuous learning, helping each other, and having fun – are brought to life every day. Join us and find out for yourself why Martin’s Point has been certified as a “Great Place to Work” since 2015.

Position Summary Medicare and US Family Health Plan (USFHP) Appeal Specialists are responsible for processing of all member appeals, non-participating provider pre- and post-service appeals, and participating provider pre-service appeals. The Specialists collaborates with Care Managers, Medical Directors and Compliance partners, as well as other internal and external partners to ensure a comprehensive appeals management process. Job Description

Key Outcomes:

+ For Medicare Focused Specialist:

+ Researches, processes and resolves Part C reconsiderations with 100% compliance

+ Prepares for, and participates in CMS, NCQA, and Health Plan audits

+ Serves as the subject matter expert for Part C appeals Medicare Managed Care Manuals

+ For USFHP Focused Specialist:

+ Researches, processes and resolves all appeals in accordance with Tricare and NCQA guidelines.

+ Serves as the subject matter expert for TRICARE and US Family Health Plan manuals and benefits pertaining to Member Appeals

+ Prepares appeals documentation within contractual and regulatory requirements

+ Independently manages multiple work queues, streams of correspondence from providers and members

+ Determines the nature of appeals and correspondences and ensures adherence to Standard Operating Procedures (SOP) to determine next steps

+ Evaluates medical claims and coverage policy documentation to determine validity of the appeal

+ Data entry of appeals to track case details, correspondences, and monitor timeliness of resolution

+ Maintains case files in organized and secure manner, both electronically and written

+ Conducts telephone work with members, providers and third-party administrators

+ Prepares case files on clinical member and provider appeals for review by clinical team members

+ Prepares and sends appeal case files for all appeal levels in accordance with regulatory requirements

+ Responsible for ensuring and monitoring effectuation of all decisions as a result of the appeal process

+ Works with leadership to develop appropriate policies and procedures

+ Brings trends and training opportunities to supervisors and management as appropriate

+ Works collaboratively and effectively with all other departments and functions to maximize operational efficiency and service and ensure consistency in addressing appeals issues

+ Maintains confidentiality while providing quality customer service to internal and external customers

+ Cross-trains to perform either Medicare or USFHP Appeals Specialist functions as needed


+ Bachelor’s Degree or equivalent experience and education

+ 3+ years experience in managed care plan required; knowledge of Medicare Advantage (for Medicare Specialist) or TRICARE (for USFHP Specialist) appeals processes and regulations strongly preferred

Skills/Knowledge/Competencies (Behaviors):

+ Demonstrates an understanding of and alignment with Martin’s Point Values.

+ Excellent written and verbal communication skills

+ Effective time management skills and organization skills

+ Must have a track record of producing high-quality work: highly accurate, demonstrates attention to detail, and reflects well on the organization

+ Strong interpersonal skills and the ability to collaborate with internal and external clients

+ Excellent customer services skills

+ Strong analytical, problem-solving and mathematical skills

+ Proficiency in Microsoft Office applications (Word, Excel, PowerPoint)

+ Strong organizational skills and able to meet deadlines (ability to prioritize and multi-task while maintaining focus on objectives).

+ Self-driven and self-motivated: ability to function independently with sound decision making

+ Take appropriate initiative while soliciting input/advice appropriately

+ Ability to handle confidential and sensitive information in a discreet and professional manner.

+ Ability to handle high volume of work while maintaining accuracy and timeliness requirements

We are an equal opportunity/affirmative action employer.

Do you have a question about careers at Martin’s Point Health Care? Contact us at: Martin’s Point Health Care is a progressive, not-for-profit organization providing care and coverage to the people of Maine and beyond. The organization operates six primary care health care centers in Maine and New Hampshire, accepting most major insurance plans. Martin’s Point also administers two health plans: Generations Advantage (Medicare Advantage plans available throughout Maine and New Hampshire), and the US Family Health Plan (TRICARE Prime® plan for active-duty and retired military families in northern New England, upstate New York, and western Pennsylvania). For more information, visit .
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Job Posting: JC251520990

Posted On: Nov 22, 2023

Updated On: Dec 03, 2023

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