Clinical Appeals Specialist

LOCATION: Remote

SALARY: Depending on qualifications & experience of candidate. This position is exempt and is not eligible for overtime compensation.

GENERAL STATEMENT OF JOB:

The Clinical Appeals Specialist is responsible for the clinical review, consultation and the generation of the Vaya Medicaid and State denial and appeals processes. This includes working with the Appeals Coordinator and Appeals Specialists in preparing Clinical Peer review referrals and Vaya notification letters to members/legal guardians and providers for reductions, suspensions, terminations or denials of services; providing support and information to members seeking to appeal a service request; action and facilitating the appeals process if requested; assist in monitoring and maintaining accurate appeals policies and procedures based on State and Federal regulations; and assist in maintaining/reporting weekly, monthly and quarterly Medicaid and non-Medicaid appeal statistics. This position also provides coordination and representation on behalf of Vaya during Mediation, State Fair Hearing Appeals, and DHHS Appeals of State-funded services processes. The Clinical Appeals Specialist works with other staff on the Member Appeals Team and with other Vaya departments to report denial and appeal outcomes, and to ensure adherence to quality and accreditation standards. This position also performs additional duties as needed to support the appeals process in collaboration with the Utilization Management Department. This position may offer Remote Work Status.

Note: This position requires access to and use of confidential healthcare information or protected health information (PHI) as described in laws addressing patient confidentiality, including, but not limited to, the federal HIPAA law, the Confidentiality of Alcohol and Substance Abuse Patient Records law, 42 CFR Part 2, and various state laws. As such, the individual filling this position shall be required to be trained regarding such laws and shall be required to observe those laws in his/her capacity as an employee of Vaya Health. The individual filling this position shall also sign a confidentiality statement as an employee of Vaya Health.

ESSENTIAL JOB FUNCTIONS:

Coordination and Generation of Vaya Medicaid and Non-Medicaid Denial and Appeal Processes:

Participate directly in the generation of Clinical and/or Administrative appeal peer review referrals, generation of denial and appeal notification correspondence and the accompanying administrative tasks (reviewing, auditing, logging, submitting, etc.). Provide support to Vaya UM and Delegated Clinical Peer Reviewers and the Appeals Supervisor in conducting their responsibilities in the appeals processes. Support the work of the Appeals Specialists in generating such correspondence and the accompanying administrative tasks. Respond to inquiries from members, guardians, providers and other Vaya staff about the denial and appeal processes. Provide assistance and action to members & guardians in submitting appeal requests. Maintain appropriate electronic denials and appeals files. Follow and track cases through all levels of the appeals processes. Maintain accuracy and maintenance of the Peer Review Log and the Denial and Appeal Logs.

Monitor, Provide Quality Assurance and Train on Vaya Denial and Appeal Processes:

Develop, review, revise and train on Member Appeals Team business processes that pertain to denials and appeals as requested by the Member Appeals Supervisor or the Senior Associate General Counsel. Monitor and audit Member Appeals Team files. Provide review and feedback on any corrective action plans as needed to improve denial and appeal processes.

Data Analysis and Reporting:

Support the Appeals Supervisor and Member Appeals Team in ensuring timely and accurate collection and reporting of data regarding denial and appeal process. This includes generation of notices in a timely manner, appeal rates, appeal outcomes, etc. Assist with analysis of data, reporting of anomalies and generation of report outs.

Litigation Liaison:

Support the Vaya Attorneys and contracted legal representatives in preparation for Vaya Appeals. Duties include: Assisting counsel in ensuring clear communication and exchange of documents are effectively made between all parties involved in appeals process; responsibility for file readiness and ensuring that Vaya representatives have appropriate documentation and are prepared for mediation and hearings; assists as needed with scheduling and attending mediations and hearings and additional meetings needed for these processes; assisting in the discovery process; assists in drafting OAH documents as directed; other tasks as requested by the Vaya legal team.

Other duties as assigned.

QUALIFICATIONS & EDUCATION REQUIREMENTS:

A Master's Degree in Special Education, Psychology, Social Work or closely related Human Services is required with two years of post-degree professional experience. Two (2) years Utilization Review/Peer Review experience preferred. Knowledge and experience with Integrated Health and Managed Care preferred. Must have active Clinical Licensure in the State of North Carolina (LCSW, LCMHC, LMFT, Psychologist).

PHYSICAL REQUIREMENTS:

This position must have the ability to establish appropriate and respectful relationships/partnerships with organizational personnel. Ability to work with a multidisciplinary team approach. Ability to assume a helping role and to intervene appropriately to meet the needs of providers, consumers or families served. Works within the established ethical guidelines developed for the profession.

KNOWLEDGE, SKILL & ABILITIES:

A demonstrated clinical knowledge of MH, SU and/or I/DD Disabilities and diagnoses, co-occurring conditions, members with such disabilities and the associated services managed by Vaya.

This position requires exceptional interpersonal skills, highly effective oral and written communication ability, and the propensity to make prompt independent decisions based upon relevant facts and established processes. Problem solving, negotiation and conflict resolution skills are essential to balance the needs of both internal and external customers.

The employee must be detail oriented, able to independently organize multiple tasks and priorities and to effectively manage an assigned workload under pressure of deadlines. A collaborative and solution focused Team approach to work and workload is necessary.

Proficiency in Microsoft Office products (such as Word, Excel, Outlook, etc.) and Vaya information system and Vaya-specific reporting systems is required.

LICENSURE:

Valid licensure or certification in profession (social work, counseling or psychology) is required. Acceptable licenses are Licensed Clinical Social Worker (LCSW), Licensed Clinical Mental Health Counselor (LCMHC), Licensed Clinical Mental Health Counselor Supervisor (LCMHCS), Licensed Psychological Associate (LPA), or Licensed Marriage and Family Therapist (LMFT).

LOCATION REQUIREMENT:

In accordance with the BH and I/DD Tailored Plan requirements mandated by the NC Department of Health and Human Services, certain Vaya Health positions are required to be filled by individuals who reside in North Carolina, meaning someone who establishes a legal domicile in North Carolina and pays income tax in North Carolina, or resides within 40 miles of the North Carolina border. New hires from outside of North Carolina will have 60 days from the date of hire to meet this requirement, if applicable to the position.

This position is required to reside in North Carolina or within 40 miles of the North Carolina Boarder.

DEADLINE FOR APPLICATION: Open Until Filled

APPLY: Vaya Health accepts online applications in our Career Center, please visit Ind.001