Government Programs A&G Resolution Specialist

Jobtailor; Harrisburg (Dauphin County); On-site; USD 52,000 - 76,000; Full time

Job summary

Jobtailor in Harrisburg, PA seeks a detail‑oriented Appeals Specialist to review policy issues, analyze CMS guidance, and manage Medicare Part C and Part D appeals. The role requires interpreting complex regulations, coordinating with PBMs, and preparing cases for QIO/IRE.

Strong communication and independent work style are essential. This position emphasizes regulatory compliance, data analysis, and cross‑functional collaboration with Marketing, Legal, and provider groups.

Qualifications

• Minimum of two years customer service or correspondence experience.
• Ability to interpret detailed policies and procedures.
• HIPAA privacy knowledge and compliance experience.
• Strong verbal and written communication skills.
• Ability to work independently and adapt to changing assignments.
• Occasional travel may be required.

Responsibilities

• Identify, review, and analyze policy and procedure issues and recommend solutions.
• Ensure compliance with organizational, CMS, and regulatory requirements.
• Research and analyze redetermination, reconsideration, and provider appeals.
• Interpret policies and CMS/HHS guidance to determine actions.
• Use PC systems, imaging technology, and PBM system to obtain case information.
• Handle Medicare Part C and Part D grievances and related appeals.
• Prepare cases for submission to QIO and IRE; attend hearings when required.
• Resolve routine and complex appeals involving benefits, claims, enrollment, and payments.

Skills

Medicare Compliance

Appeals Processing

Customer Service

Analytical Skills

Effective Communication

Education

High School diploma

Bachelor's degree in business administration or health care administration

Tools

Facets System

PBM System

Microsoft Word

Microsoft Excel

PowerPoint

Imaging Technology

Secure IT

Job description

• Identify, review, and analyze policy and procedure issues and recommend solutions
• Ensure compliance with organizational, CMS, and other regulatory requirements
• Research and analyze customer redetermination, reconsideration, and provider appeals
• Determine appropriate actions by interpreting policies, procedures, CMS guidance, and HHS guidance
• Use PC systems, manuals, online references, imaging technology, the appeals system, and PBM system to obtain case information
• Handle Medicare Part C and Part D grievances and quality-of-service and quality-of-care complaints
• Prepare cases for submission to the QIO and IRE
• Prepare case files and attend administrative law hearings when required
• Resolve routine and complex appeals involving benefits, claims, billing, enrollment, legal requests, Medicare Secondary Payer, payments, reinstatements, conversions, refunds, and related matters
• Conduct job-related instructional sessions as requested by management
• Respond to appeals by telephone, correspondence, on-site interaction, fax, Secure IT, email, and personal interviews
• Interact with the PBM and IRE to resolve cases
• Monitor appeals through system-generated reports for accurate and timely resolution
• Provide instructions to appropriate Plan areas for issue resolution
• Contact internal and external entities, including groups, providers, Marketing, Legal, Host Plans, PBM, IRE, QIO, ALJ, and CMS
• Update the Facets appeal module or Work Desk with appeal information and status
• Report appeal trends and processing, documentation, claims, enrollment, benefits, and pharmacy issues to management
• Conduct peer reviews, provide audit support, mentor and train staff as assigned
• Support Marketing, brokers, customers, and the walk-in lobby operation in the Elmerton Avenue office
• Complete required training and acknowledgements and identify process improvements

Requirements

• Minimum of two years customer service or correspondence experience, or experience/training in a writing-intensive role
• Extensive experience with customer interaction preferred
• High School degree and demonstrated work experience of no less than two years required
• Bachelor’s degree in business administration, health care administration or a related field, or equivalent demonstrated work experience of no less than two years
• Effective and professional verbal and written communication skills
• Ability to understand and interpret detailed policies and procedures
• Understanding of HIPAA privacy requirements for Protected Health Information
• Ability to work independently and adapt to changing assignments and work environments
• Analytical, organizational, and problem-solving skills
• Familiarity with PC hardware and software, Microsoft Word, Excel, phone equipment, calculator, fax, copier, and other department hardware
• Competency in Windows, Outlook, Word, Internet Explorer, Excel, and PowerPoint
• Above-average reading, writing, and arithmetic skills
• Knowledge of Medicare Advantage, Medicare Part D, Medicare Supplemental, Dental, Vision, Chiropractic, Prescription Drug, Benefits Management, and Disease Management programs
• Knowledge of PBM and Facets health plan administration systems
• Knowledge of benefits administration, customer billing, claims processing, and general procedures
• Knowledge of CMS Chapters 6, 13, and 18 appeals regulations and processes
• Knowledge of Medicare compliance, marketing, and sales regulations
• Knowledge of NCQA, BCBSA MTM, HIPAA quality and timeliness guidelines
• Knowledge of online inquiry and appeal systems and coding structures
• Knowledge of Medicare enrollment exchange systems and applicable CMS regulations
• Must be able to work 37.5 hours per week
• Some travel into the office on weekends may be required for training sessions and/or between buildings

Core Competencies

Demonstrates expertise in Medicare compliance, appeals processing, and customer service, with strong analytical and problem-solving skills. Proficient in interpreting policies and procedures while ensuring adherence to regulatory requirements.

Highest-signal resume keywords

• Medicare Compliance
• Appeals Processing
• Customer Service Experience
• Analytical Skills
• Effective Communication

ATS Optimization Keywords

Hard Skills

• Policy Interpretation
• Claims Processing
• Benefits Administration
• Customer Billing
• Data Analysis
• Regulatory Compliance
• HIPAA Knowledge
• Medicare Advantage Knowledge
• Medicare Part D Knowledge
• Facets System Knowledge

Soft Skills

• Problem-Solving
• Organizational Skills
• Adaptability
• Mentoring
• Instructional Skills

Industry Keywords

• CMS Regulations
• NCQA Guidelines
• BCBSA MTM
• Medicare Enrollment
• Quality of Care
• Quality of Service
• Administrative Law Hearings
• Customer Interaction
• Process Improvements
• Training and Development

Tools & Technologies

• PC Systems
• Microsoft Word
• Microsoft Excel
• Outlook
• Internet Explorer
• PowerPoint
• Imaging Technology
• Appeals System
• PBM System
• Secure IT