Fair Hearing - Medical Insurance

Unison Health; Toledo (OH); On-site; USD 70,000 - 95,000; Full time

Benefits offered by this job

PTO starting at 16 days/yr

Medical with federal minimum deducti

Dental and Vision coverage

Retirement plan and employer contrib

Job summary

Unison Health in Ohio seeks a Medicaid Appeals, Grievance & Fair Hearing Officer to oversee Medicaid grievances, appeals and State Fair Hearing activities in compliance with 42 CFR Part 438. This senior role serves as the organization’s SME on adverse benefit determinations and authorization denials.

You will coordinate with clinical, utilization management, billing and provider teams to gather documentation, prepare hearing packets, and represent the organization during Ohio Medicaid State Fair

Qualifications

• Bachelor’s degree in health administration, Social Work, Public Administration, Legal Studies, or a related field required.
• Master’s degree or advanced credential preferred (e.g., JD, RN, LISW-S, LPCC-S).
• Experience managing Medicaid grievances, appeals, and/or State Fair Hearing processes.

Responsibilities

• Oversee and manage Medicaid grievances and appeals related to service denials, reductions, suspensions, terminations, and failure-to-act cases in accordance with regulatory requirements.
• Ensure Notices of Action are issued and reviewed for compliance, including required timelines, content, appeal rights, and continuation of benefits provisions.
• Coordinate with clinical, utilization management, billing, and provider teams to gather documentation and support appeal determinations.
• Lead the preparation and coordination of Ohio Medicaid State Fair Hearings, including appeal summaries, hearing packets, and supporting documentation.
• Represent or support the organization during hearings before the Ohio Department of Job and Family Services (ODJFS) Bureau of State Hearings.
• Provide guidance and training to providers and staff regarding Medicaid appeals, grievances, hearing rights, and regulatory requirements.
• Monitor, identify, and escalation compliance concerns, including potential issues related to denials, recoupments, and adverse benefit determinations.
• Analyze grievance and appeal trends, prepare reports for leadership, and recommend quality improvement and risk mitigation strategies.

Skills

Medicaid regulations knowledge

Grievances & appeals management

Communication skills

Regulatory compliance

Analytical problem-solving

Education

Bachelor's degree

Master's degree preferred

Job description

Description

Why Join Unison Health?

Unison Health provides a mission-driven work environment focused on staff support, professional growth, and work-life balance. We are committed to helping our employees thrive while making a lasting difference in the lives of children and families. For over 50 years, Unison Health has proudly supported individuals, families, and communities across Ohio. From behavioral health and substance abuse treatment to primary healthcare, we are dedicated to our mission: Making Lives Better.

• Paid Time Off (PTO) Starting at 16 Days/Year
• Medical with federal minimum deductibles
• Dental and Vision coverage
• Retirement planning and employer contribution

Position Summary:

Medicaid Appeals, Grievance & Fair Hearing Officer is a senior administrative and compliance role responsible for overseeing Medicaid grievances, appeals, and State Fair Hearing activities in compliance with 42 CFR Part 438. This position serves as the organization’s primary subject matter expert on adverse benefit determinations, authorization denials, continuation of benefits, and Ohio Medicaid State Fair Hearing preparation and representation.

Key Responsibilities & Role Highlights:

• Oversee and manage Medicaid grievances and appeals related to service denials, reductions, suspensions, terminations, and failure-to-act cases in accordance with regulatory requirements.
• Ensure Notices of Action are issued and reviewed for compliance, including required timelines, content, appeal rights, and continuation of benefits provisions.
• Coordinate with clinical, utilization management, billing, and provider teams to gather documentation and support appeal determinations.
• Lead the preparation and coordination of Ohio Medicaid State Fair Hearings, including appeal summaries, hearing packets, and supporting documentation.
• Represent or support the organization during hearings before the Ohio Department of Job and Family Services (ODJFS) Bureau of State Hearings.
• Provide guidance and training to providers and staff regarding Medicaid appeals, grievances, hearing rights, and regulatory requirements.
• Monitor, identify, and escalation compliance concerns, including potential issues related to denials, recoupments, and adverse benefit determinations.
• Analyze grievance and appeal trends, prepare reports for leadership, and recommend quality improvement and risk mitigation strategies.

Education & Experience Requirements:

• Bachelor’s degree in health administration, Social Work, Public Administration, Legal Studies, or a related field required.
• Experience managing Medicaid grievances, appeals, and/or State Fair Hearing processes required.
• Working knowledge of Medicaid regulations, including 42 CFR Part 438.
• Strong written and verbal communication skills, with the ability to prepare formal appeal summaries and case documentation.
• Master’s degree or advanced credential preferred (e.g., JD, RN, LISW-S, LPCC-S, or equivalent).
• Experience representing or supporting cases in Ohio Medicaid State Fair Hearings preferred.
• Knowledge of behavioral health, substance use disorder (SUD), and/or long-term services and supports (LTSS) preferred.
• Strong organizational, analytical, and problem-solving skills with attention to detail and regulatory compliance.

Unison Health is an Equal Opportunity Employer (EOE).

Equal Opportunity Employer
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