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J203879

Medicare Appeals Specialist RN

Highmark Inc.

  • Company Highmark
  • Home, PA
  • Claims
  • Full time
  • Day (United States of America)

Company :

Highmark Inc.

Job Description : 

JOB SUMMARY

The job conducts and documents thorough investigations of Part C, Part D, QIO and Administrative Law Judge Case Types, communicating resolution to members in accordance with Center for Medicare and Medicaid Services (CMS) requirements. Requires broad knowledge of plan products, medical policy requirements, processes and enrollment rules. Responsible for all aspects of Part C and D clinical appeals , up to and including decision making, considering potential impacts to regulatory compliance as well as CMS star ratings. Provides support to non-clinical appeals and ensures correct authorization of services.

ESSENTIAL RESPONSIBILITIES

  • Complete and document thorough clinical investigation of all Part C, Part D, QIO Home Health and ALJ appeals. Perform research, request and review all related relevant documentation and assemble case file. Ensure accurate documentation of cases in the appeals management system, maintaining compliance with CMS reporting and data validation requirements. Ensure effective and compliant effectuation of appeals.
  • Review outcome of appeal, either independently or in conjunction with medical director.  Communicate effectively with members, providers,  and colleagues, successfully articulating issues, problems and solutions. 
  • Recommend process efficiencies, strategies for improvement and/or solutions to align with business strategies.  
  • Participate in process improvement meetings and/or discussions, recommending process efficiencies and/or strategies
  • for improvement.
  • Ensure quality assurance of appeal work, assist in development of desktop procedures and/or training materials.
  • Other duties as assigned or requested.

EDUCATION

Required

High School/GED

Substitutions

None

Preferred

Bachelor's in Nursing

EXPERIENCE

Required

  • 3 years Clinical Nursing

Preferred

  • 3 years Appeals Review
  • 3 years Utilization Management Review
  • 3 years Regulatory Compliance

LICENSES or CERTIFICATIONS

Required

  • PA RN License
  • WV RN License (within 3 months after hire)

Preferred

  • None

SKILLS

  • Critical Thinking
  • Organization
  • Time Management
  • Decision Making
  • Written Communication
  • Cross-Functional Collaboration
  • Microsoft Word

Language (Other than English)

None

Travel Requirements

0% - 25%

PHYSICAL, MENTAL DEMANDS and WORKING CONDITIONS

Position Type

Office-Based

Teaches / trains others regularly

Occasionally

Travel regularly from the office to various work sites or from site-to-site

Does Not Apply

Works primarily out-of-the office selling products/services (sales employees)

Never

Physical work site required

Yes

Lifting: up to 10 pounds

Frequently

Lifting: 10 to 25 pounds

Never

Lifting: 25 to 50 pounds

Never

Disclaimer: The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job.

Compliance Requirement: This position adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies.


As a component of job responsibilities, employees may have access to covered information, cardholder data, or other confidential customer information that must be protected at all times. In connection with this, all employees must comply with both the Health Insurance Portability Accountability Act of 1996 (HIPAA) as described in the Notice of Privacy Practices and Privacy Policies and Procedures as well as all data security guidelines established within the Company’s Handbook of Privacy Policies and Practices and Information Security Policy. Furthermore, it is every employee’s responsibility to comply with the company’s Code of Business Conduct. This includes but is not limited to adherence to applicable federal and state laws, rules, and regulations as well as company policies and training requirements. 

Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities, and prohibit discrimination against all individuals based on their race, color, religion, sex, national origin, sexual orientation/gender identity or any other category protected by applicable federal, state or local law. Highmark Health and its affiliates take affirmative action to employ and advance in employment individuals without regard to race, color, religion, sex, national origin, sexual orientation/gender identity, protected veteran status or disability.

Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities, and prohibit discrimination against all individuals based on their race, color, age, religion, sex, national origin, sexual orientation/gender identity or any other category protected by applicable federal, state or local law. Highmark Health and its affiliates take affirmative action to employ and advance in employment individuals without regard to race, color, age, religion, sex, national origin, sexual orientation/gender identity, protected veteran status or disability. 

EEO is The Law

Equal Opportunity Employer Minorities/Women/Protected Veterans/Disabled/Sexual Orientation/Gender Identity ( https://www.eeoc.gov/sites/default/files/migrated_files/employers/poster_screen_reader_optimized.pdf )

We endeavor to make this site accessible to any and all users. If you would like to contact us regarding the accessibility of our website or need assistance completing the application process, please contact number below.

For accommodation requests, please contact HR Services Online at HRServices@highmarkhealth.org

California Consumer Privacy Act Employees, Contractors, and Applicants Notice


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