Medicare Appeals Analyst - New York, NY

MetroPlus; New York (NY); On-site; USD 50,000 - 90,000; Full time

Job summary

An established industry player is seeking a dedicated Medicare Appeals Analyst to enhance the healthcare experience for New Yorkers. In this pivotal role, you will conduct comprehensive reviews of claims and appeals, ensuring compliance with Medicare guidelines and internal policies. Your analytical skills will be put to the test as you assess claims documentation and collaborate with various departments to resolve complex cases. Join a team that values compassion and collaboration, where your contributions will directly impact the quality of care provided to the community. If you are passionate about healthcare and eager to make a difference, this opportunity is for you.

Qualifications

• Bachelor's degree plus 1 year of related claim processing experience required.
• Knowledge of Medicare Advantage plans and health care billing services is essential.

Responsibilities

• Conduct thorough reviews of Medicare Advantage claim payment appeals.
• Collaborate with departments to resolve complex cases and maintain accurate records.

Skills

Claim Processing

Medicare Advantage Knowledge

Communication Skills

Analytical Skills

Customer Focus

Education

Bachelor's Degree

Associate's Degree

Tools

Microsoft Office Suite

Electronic Health Records (EHRs)

Job description

Empower. Unite. Care.

MetroPlusHealth is committed to empowering New Yorkers by uniting communities through care. We believe that healthcare is a right, not a privilege. If you have compassion and a collaborative spirit, work with us. You can come to work being proud of what you do every day.

About NYC Health + Hospitals

MetroPlusHealth provides the highest quality healthcare services to residents of Bronx, Brooklyn, Manhattan, Queens, and Staten Island through a comprehensive list of products, including, but not limited to, New York State Medicaid Managed Care, Medicare, Child Health Plus, Exchange, Partnership in Care, MetroPlus Gold, Essential Plan, etc. As a wholly-owned subsidiary of NYC Health + Hospitals, the largest public health system in the United States, MetroPlusHealth's network includes over 27,000 primary care providers, specialists, and participating clinics. For more than 30 years, MetroPlusHealth has been committed to building strong relationships with its members and providers to enable New Yorkers to live their healthiest life.

Position Overview

The Medicare Appeals Analyst is responsible for conducting thorough and timely reviews of claim payment appeals related to denied or partially paid claims for services rendered to Medicare Advantage (Part C) enrollees. The analyst will analyze claims data, medical records, and plan benefit information to determine if the denial or partial payment was appropriate based on Medicare coverage guidelines, plan policies, and applicable regulations.

This individual will assist in developing, creating, and implementing call center Appeals processes and procedures, as well as making recommendations for enhancements to training materials as needed to enhance the overall MetroPlusHealth customer’s experience.

Job Description

• Reviews, analyzes, and processes Part C payment appeals within established timeframes in accordance with regulatory requirements and internal policies.
• Analyzes claims documentation, medical records, and other relevant information to assess the correct payment of services provided.
• Applies knowledge of Medicare coverage guidelines, plan benefits, and coding principles to evaluate claims and render informed determinations.
• Collaborates with other departments, such as claims processing, utilization management, provider relations, and/or legal, to gather information and resolve complex cases.
• Drafts clear and concise appeal determination letters, explaining the rationale behind the decision and citing relevant policies and regulations using verbiage that is easily comprehended by all populations and experience levels.
• Maintains accurate and detailed records of all appeal activities, including case notes, correspondence, and final determinations.
• Escalates issues to Senior Management as appropriate.
• Responsible for drafting case files to be shared with the IRE.
• Stays up-to-date on changes in Medicare regulations, plan policies, and coding guidelines.
• Participates in ongoing training and development opportunities to enhance knowledge and skills.
• Participates in audit readiness and reviews.
• Contributes to the development and maintenance of customer services policy, procedures, internal desk manuals, and workflows in support of appeals needs.
• Supports the use of knowledge management tools, including new workflows, and troubleshoots problems.
• Participates in User Acceptance Testing (UAT) for new systems or implementations and provides feedback.
• Other duties as assigned by the Director of Call Center Quality and Compliance and/or the Senior Director of the Call Center Operations.

Minimum Qualifications

• Bachelor’s degree plus 1 year of related claim processing experience or
• Associate’s degree with a minimum of 3 years related experience.
• Knowledge of Health Plan Products. Experience working with Medicare Advantage plans is highly desirable.
• Knowledge of state and federal regulations pertaining to Medicare Advantage.
• Knowledge of Managed Care.
• Familiarity with claim processing methodologies and systems, electronic health records (EHRs), and medical terminology.
• Familiarity with health care billing services and reimbursement methodologies.
• Proficiency in Microsoft Office Suite and other relevant software applications.
• Bilingual is a plus (Spanish, Bengali, Creole, Mandarin, Cantonese, French).

Professional Competencies

• Exceptional written and verbal communication skills with the ability to convey complex information in a clear and concise manner.
• Integrity and Trust
• Customer Focus
• Functional/Technical skills

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