Appeals Specialist - Leading Industry Pay

J29 Inc. is looking for an Appeals Specialist with skill sets ranging from strong communication, customer service abilities through inbound and outbound call handling, ability to freely operate a computer, critical thinking, decision making experience, as well as a strong attentiveness to detail, to join our experienced team to continue delivery to our customers. J29 is a government-focused technology company with a history of strong performance for Federal and State agencies. J29 is happy to be kicking off new work to continue delivering on improvements to the healthcare system at the Centers for Medicare and Medicaid Services (CMS).  

As an Appeals Specialist, you will support our team that conducts and performs reviews on Medicare appeals, as well as helping our team making reconsideration decisions on these appeals. In support of CMS, you will be responsible for aiding our team in data entry and records decisions related to Late Enrollment Penalty (LEP) appeals, and reconsideration appeals for denied coverage that involve Medicare Part D – Prescription Drug Plans. Part D can be offered through private companies either as a stand-alone plan, for those enrolled in Original Medicare, or as a set of benefits included with your Medicare Advantage Plan.  

Performs moderately complex (journey-level) appeals work. Researches and responds to inquiries from providers, suppliers, beneficiaries, health plans, or others involved in the appeals/dispute process. May conduct phone calls with appellants for the purpose of scheduling phone discussions with the company decision maker. Works under moderate supervision, with moderate latitude for the use of initiative and independent judgement. 

Essential Duties:  

• Provides customer service and researches and responds to inquiries received by phone, fax, mail, or email timely and accurately.  
• Interprets requests and determines appropriate response or course of action to bring to resolution with minimal assistance.  
• Conducts research using online federal regulations, review Medicare and Medicaid policy and guidelines to complete an accurate and well-supported decision.  
• Screens receipts to determine the issue addressed in the correspondence and address timely which may involve forwarding cases to the appropriate person or entity timely.  
• Logs receipts and enters into database.  
• Trends receipts/issues and schedules coordination meetings as required.  
• Prepares and sends professionally worded letters, emails or faxes.  
• May initiate, schedule and coordinate reconsideration phone discussions between suppliers and decision makers by coordinating with appellants on schedule adherence and reschedule as needed, reviewing decision maker calendars to ensure phone discussions are held as scheduled with minimal interruptions, and validate additional documents submitted by appellant and that verbal testimonies are received and images are uploaded into appropriate system.  
• Participates in special projects and performs other duties as assigned.  

Minimum Qualifications  

Education  

• High School Diploma, at minimum  

Experience  

• Three (3) years of general office experience  

• College education or technical training in administration, business, or related areas may be substituted for experience on a year per year basis. (Education requirements may be satisfied by full-time education or the prorated part-time equivalent.)  

• One (1) year of Medicare Qualified Independent Contractor appeals experience OR One (1) year of professional business writing experience in the healthcare, customer service or legal industries  
• Experience directly relevant to the specific task order or project, preferred  

Duties:  

• Drafts a non-medical LEP decision that is clearly written and understandable, comports with the Centers for Medicare & Medicaid Service (CMS) regulations and policy, and supports the evidence in the record.   
• Investigates arguments of creditable coverage proffered by enrollees in support of removing a LEP for uncovered months; this includes reviewing enrollee appeal letters, reviewing documents furnished by enrollees in support of proof of creditable coverage, reviewing Part D plan case files, and calling enrollees, employers or other insurers, and Part D plans, as appropriate, to verify creditable coverage.   
• Documents actions taken during the course of investigation and research into determining creditable coverage, e.g., documents telephone calls to enrollees or insurers and information relayed from these individuals.  
• Determines whether there is good cause for late filing of an appeal by reviewing the enrollee appeal letters and case files submitted by plans to determine if there is good cause in accordance with Medicare rules and policy.   
• Ensures that all appeal issues raised have been researched and addressed. 
• Provides a fair and impartial decision based on the presentation of facts, CMS regulations and policies, other relevant information.  
• Ensures all documents are releasable and do not violate any Privacy Act provisions.  
• Conducts research using online CMS regulations and policy provisions, subscriber materials, and CMS system including the Eligibility and Enrollment Medicare Online (ELMO)to adjudicate decisions that are accurate and well-supported. 
• Makes sound, independent decisions based on the evidence in the record in accordance with CMS regulations and policies, or subscriber materials.   
• Stays abreast of changes in CMS rules, policies and other applicable guidance relative to LEP decisions.    

• Participates in special projects and performs other duties as assigned. 

Knowledge, Skills and Abilities  

Working Knowledge of  

• Research techniques  
• Medicare appeals program  
• Medical terminology  
• Applicable systems and applications, laws, rules and regulations  

Proficient Skill in  

• Preparing correspondence/documents using correct spelling, grammar and punctuation; proofreading and reviewing documents for clarity and consistency  
• Prioritizing and organizing work assignments  
• The use of personal computers and applicable programs, applications and systems  

Some Skill in  

• Researching, analyzing and interpreting policies and state and federal laws and regulations  

J29, Inc. is committed to hiring and retaining a diverse workforce. We are proud to be an Equal Opportunity/Affirmative Action Employer, making decisions without regard to race, color, religion, creed, sex, sexual orientation, gender identity, marital status, national origin, age, veteran status, disability, or any other protected class.  J29, Inc. is a proud Veteran friendly employer.