Appeals Analyst - Phoenix, AZ - Full-time / Part-time

Position Description:

Welcome to one of the toughest and most
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opportunities for advancement. Join us and start doing your life's best work.

Appeals and
Grievances Department [Grievance System]. Consults with staff, including but
not limited to QM, Provider relations staff, Medical Management (including
Prior Authorization), and Member services, Compliance and Legal.

Primarily, position
performs claims, provider network, and State regulator contract and rules
research and data mining. Position is responsible for the timely and accurate
investigation of Grievance System administrative and compliance with State
contracts requirements. Accordingly, to investigate, file creation, attending
staffing for member grievances and appeals and provider
claims disputes.

Primary Responsibilities:

• Prepare for review,
  responses to subpoenas, garnishments, record requests, liens, etc.
• Familiarity with Federal
  and State laws, regulations, including A.A.C. Title 9, Chapters 34, State
  Medicaid policies, procedures, reimbursement, etc.
• Maintain internal
  logs and prepare reports for health plan management and meeting State
  submission requirements.
• Assist in
  developing, implementing and timely preparing system reports and analysis.
• Helps in data and
  report (trending) preparation to meet health plan and State timeliness
  requirements.
• Investigate member
  appeals to assist in rendering timely and accurate decisions within
  AHCCCS-mandated criteria and within production and quality standards.
• Schedule and assist
  in preparation of witness (e.g., Medical Director) and arrange for
  appearance/telephonic requests of witnesses as well as exhibit gathering.
• Assists in
  preparation for and presentation of Medicaid grievances and claim disputes
  towards timely resolution, up to and including, in administrative hearings on government-funded
  managed health care programs: AHCCCS,
  DDD, Evercare and CRS matters.
• Conduct
  pre-administrative hearing investigation for appeals and claim disputes,
  document the findings (in the appeal files), help identify common factors as to
  whether appeal or claim dispute is a candidate for settlements and assist in
  settlement negations, as needed.
• Assists with filing Grievances and Appeals / Claim Dispute /
  request State Fair Hearing process; distinguishing between an inquiry, a
  Grievance, an Appeal, a Claim Dispute and a quality of care issue and know how
  to triage, resolve or refer incoming calls/correspondence to appropriate
  personnel.
• Docket hearing notices, contact State/Office of
  Administrative hearings, establish duties and time-frames in connection with
  each hearing and disseminate information with follow-up as appropriate.
• Provide testimony
  on behalf of the health plan and administrative hearing and represent the
  health plan at hearing when necessary and appropriate.
• Assists with
  internal segment and external vendor coordination, e.g., third-party liability,
  lien, primary insurance/coordination of benefit issues, questions.
• Other duties as
  assigned by manager