Subject Matter Expert

Maryland  ‐ Onsite
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Keywords

Description

As a global business and technology consulting services leader, Enclipse focuses on delivering tangible solutions. 

By employing a team committed to questioning and challenging the status quo, Enclipse has established a culture that encourages independent thought, innovation, and flexibility.

If you join Enclipse, you can expand your technology platform while working for the Nation's most dynamic Health Care Leader.

We Provide:

- Class A Benefits  that Start ASAP
- The Personal Touch -- You deserve it, We deliver it!

Contract Terms- W2

Rockville, MD

10 month +

This position also has compliance accountability and/or responsibility for client's policies and procedures, the Principles of Responsibility, accreditation standards, and applicable federal, state, and local laws and regulations. 

ACCOUNTABILITIES: 
1. Provides accurate and comprehensive case documents to interdisciplinary Appeals Committee and/or Associate Medical Director and Director, Member Services to support and facilitate decisions. Participates in discussion to achieve disposition of the member's issues. 
2. Coordinates, researches and collects information from internal/Health Plan departments and external providers to respond to member appeals. 
3. Analyzes, compiles and records information from internal and external sources to develop consistent, defensive and persuasive arguments in the course of resolving appeals. 
4. Ensures the Health Plan's compliance with reporting timeframes established under regulatory and contractual requirements. 
5. Manages all written communication to members or designees regarding appeals procedures, status, outcome and basis for decisions. 
6. Conducts expert investigation, review and prepares appeals documentation and case summaries within established timeframes and protocols. 
7. Balances the voice of the member with the policies of the Health Plan. 
8. Manages all written communications to regulatory agencies regarding procedures, status, outcomes and basis for decisions on appeals. 
9. Maintains current knowledge of regulations and compliance standards, policies and procedures relating to Commercial member/provider complaints and appeals. 
10. Utilizes MACCESS system to ensure appropriate documentation for reporting purposes and adequate case documentation and tracking from date of receipt through completion. 
11. Analyzes Membership Administration records for processing errors; recommends immediate corrective action to department supervisor and/or jurisdiction under which member enrolled. 
12. Establishes and maintains inter-departmental relationships within the Health Plan and Medical Group to facilitate the resolution of appeals cases. 
13. May participate in responsibility for responding to the expedited appeals pager. Works closely with MAPMG to ensure expedited cases are processed and completed within mandated timeframes. 
14. Composes appropriate, clear responses to members/providers on the resolution of cases involving complaints/quality of care issues. 
15. Develops and supports special projects. 
Performs other duties as directed. 

MINIMUM REQUIREMENTS - Relevant Years of Experience: 
Two years of Appeals and Correspondence experience in a health insurance environment required or one year's experience in client Member Services.
Solid decision- making and problem- solving abilities coupled with outstanding communication skills required.
Well developed organizational skills.
Working knowledge of MACESS preferred. Working knowledge of standard practices of business writing or Health Insurance industry's terminology and concepts

MINIMUM REQUIREMENTS - Relevant Education: 
High School Diploma or equivalent required.
College level courses to include writing and Marketing/business administration preferred
Bachelor's Degree preferred 

Education and/or Classes: 

License, Certification and/or Designation: 
Current appeals analyst with a minimum of one-year's experience strongly preferred 

Essential Functions (ie bending, lifting, and mobility): 

Competencies (List 6-8 from attached list, typically some from each area): 
Customer focus 
Process management 
Informing 
Organizing 
Results 
Functional/technical skills 
Building team spirit 

Start date
Immediate
Duration
10 month +
(extension possible)
From
Enclipse Corp.
Published at
21.03.2013
Project ID:
507637
Contract type
Freelance
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