Under the general supervision of the Director of Customer Services, the Customer Service Appeals Specialist is responsible for assuring that the Detroit Wayne Integrated Health Network's (Network) appeals process is carried out in accordance with local, state and federal regulations, BBA, Mental Health Code mandates, the MDHHS contract and National Committee on Quality Assurance (NCQA) standards. The Customer Service Appeal Specialist works collaboratively with the Network's Appeals Management to ensure that the Network's missions and goals are achieved. PRINCIPAL DUTIES AND RESPONSIBILITIES:
- Administers the appeals process and procedures in accordance with all local, state, federal and other regulatory bodies along with the Network's policies and procedures.
- Monitors the appeals process for the Network and contract providers to ensure compliance with established policies and procedures.
- Collaborates and coordinates with all dispute resolution and appeals units to ensure that issues are addressed in accordance with mandated policies and procedures.
- Enforces the Network's policies on Local Appeals, Local Dispute Resolution, State Fair Hearing and Mediation processes.
- Maintains a database that tracks and monitors appeals and final dispositions.
- Reviews and analyzes appeal logs and data.
- Reports trends and patterns for the appeal process.
- Provides weekly and monthly reports on appeals activity for both internal and external entities.
- Provides technical assistance to Network staff and contractors on the appeals process and applicable dispute resolution protocols.
- Provides Due Process information, referral, linkage, and follow through for telephone and walk-in inquiries.
- Assists in the preparation of the State Administrative Hearing /Medicaid Fair Hearing process.
- Develops, implements and conducts on-going appeals training modules.
- Develops and maintains standardized appeals educational and informational materials (i.e. handbooks, posters, forms, policies etc.).
- Facilitates periodic meetings with network provider appeals contacts to address Network updates and issues applicable to appeals activities.
- Develops and enacts the Network and contractor Appeals Compliance Audit Review tool(s) in accordance with Federal, State, and Local requirements.
- Assists in monitoring and training the Network on the disenrollment process.
- Oversees the Explanation of Benefits process for Medicaid and MI Health Link members.
- Performs related duties as assigned.
KNOWLEDGE, SKILLS AND ABILITIES (KSA'S):
- Knowledge of the appeals and grievance processes for behavioral health systems.
- Knowledge of dispute resolution practices and procedures.
- Knowledge of customer service principles and practices.
- Knowledge of DWIHN policies, procedures and practices.
- Knowledge of the DWIHN provider network and community resources.
- Knowledge of the Michigan Mental Health Code.
- Knowledge of MDHHS policies, rules, regulations and procedures.
- Knowledge of compliance standards.
- Knowledge of the Federal Confidentiality Regulations, 42 CFR, Part 2.
- Knowledge of documents / regulations that govern the provision of mental health services, e.g., Medicaid Manual Mental Health and Substance Abuse Chapter III, State Plan for Medicaid, Michigan Department of Health and Human Services Quality Plan, BBA requirements and the Mental Health Code.
- Knowledge of the principles, practices, and techniques of fact finding and conducting investigations.
- Assessment skills.
- Organizational skills.
- Analytical skills.
- Time Management skills.
- Report writing skills.
- Decision Making skills.
- Customer Service skills.
- Communication skills.
- Active Listening skills.
- Skill at meeting deadlines
- Multitasking skills.
- Prioritizing skills.
- Written communication skills.
- Accuracy and detailed oriented skills.
- Investigation skills.
- Training skills.
- Computer skills (Word, Excel, Access, Power Point, Outlook, Teams)
- Ability to communicate orally.
- Ability to communicate in writing.
- Ability to work effectively with others.
- Ability to act ethically and with confidentiality.
- Ability to work with an ethnically, linguistically, culturally, economically and socially diverse population.
- Judgement/Reasoning ability.
REQUIRED EDUCATION:
- Bachelor's degree from a recognized college or university.
REQUIRED EXPERIENCE:
- Four (4) years of full-time paid professional experience in the field of complex cross-functional appeal/dispute resolution or consumer relations.
NOTE: Must have experience working with due process procedures (i.e. complaints, appeals and/ or grievances).REQUIRED LICENSE(S).A valid State of Michigan Driver's License with a safe and acceptable driving record.WORKING CONDITIONS:Work is usually performed in an office setting but requires the employee to drive to different sites throughout Wayne County and the State of Michigan. This position can work remotely with supervisory approval. Currently this position is a hybrid position.This description is not intended to be a complete statement of job content, rather to act as a general description of the essential functions performed. Management retains the discretion to add or change the position at any time. Please Note: DWIHN requires proof of being fully vaccinated for COVID-19 as a condition of employment. Medical or religious accommodations or other exemptions that may be required by law, will be approved when properly supported. Further information will be provided during the recruitment process. The Detroit Wayne Integrated Health Network is an Equal Opportunity Employer