HealthAxis Group, LLC

Compensation

Full Description

COMPANY OVERVIEW: HealthAxis is a prominent provider of core administrative processing system (CAPS) technology, business process as a service (BPaaS), and business process outsourcing (BPO) capabilities to healthcare payers, risk-bearing providers, and third-party administrators. We are transforming the way healthcare is administered by providing innovative technology and services that uniquely solve critical healthcare payer challenges negatively impacting member and provider experiences. We live and work with purpose, care about others, act with integrity, communicate with transparency, and don’t take ourselves too seriously. We're not just about business – we're about people. Our commitment to a people-first approach shapes everything we do, from collaborating as a team to serving our valued clients. We believe that creating a vibrant and human-centric environment can inspire engagement, empower our team members, and ignite a sense of purpose in all that we accomplish. APPLICATION INSTRUCTIONS: We're moving quickly to fill these roles, so we appreciate your attention to detail during the application process! To help ensure a smooth and efficient review process, please complete all sections of the application form--incomplete applications may not be considered. PURPOSE AND SCOPE: The Full-Time, Temporary Appeals and Grievances Specialist uses discretion and judgment with the authority to make independent decisions on Member Appeals and serves as an IRE liaison and a liaison with other external regulatory entities such as the Administrative Law Judges (ALJ), Medicare Appeals Council (MAC), and Medicaid Fair Hearing offices which affects a significant part of the business. PRINCIPAL RESPONSIBILITIES AND DUTIES: Has the authority to make independent decisions on Appeals which has significant impact on the company’s overall performance and CMS scoring. Serves as a liaison to the IRE and independently prepares and files all Member IRE cases to Maximus. Independently coordinates and prepares all ALJ submissions/hearings, MAC submissions/hearings, and Medicaid Fair Hearings. Coordinates and prepares all cases files for Medicare/Medicaid audits. Responsible for interpretation of company policies while providing education and guidance in the day-to-day operations of the staff and acts as resource for issues. Serves as a subject matter expert in corresponding and communicating with providers and members or members' representatives as needed during appeal processing. Serves as a subject matter expert when interacting with other departments including Customer Service, Claims, Provider Relations, and Pharmacy to resolve member appeals. Implements, develops, and presents ideas for performance and process improvement within the department. Notifies Manager or other appropriate parties of identified patterns of appeals, claim errors, configuration issues, or other systemic problems identified during appeal processing. Assists Department Manager with workflows and projects. CUSTOMER SERVICE: Responsible for driving the HealthAxis culture through values and customer service standards. Accountable for outstanding customer service to all external and internal contacts. Develops and maintains positive relationships through effective and timely communication. Takes initiative and action to respond, resolve and follow up regarding customer service issues with all customers in a timely manner. EDUCATION, EXPERIENCE AND REQUIRED SKILLS: Bachelor’s degree preferred; Associate degree from an accredited institution of higher learning required, or equivalent credit hours may be substituted. Five years related Medicare/Medicaid HMO Appeals and Grievance experience preferred. Excellent oral and written communication skills including good grammar, voice, and diction. Able to read and interpret documents and calculate figures and amounts. Proficient in MS Office with strong computer and keyboarding skills. Excellent customer service skills (friendly, courteous, and helpful).