Medicare Appeals Analyst

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 network includes over 27,000 primary care providers, specialists and participating clinics. For more than 30 years, MetroPlusHealthhas 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 recommendation for enhancements to training materials as needed to enhance the overall MetroPlus Health customer's experience.

• 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.
• Apply knowledge of Medicare coverage guidelines, plan benefits, and coding principles to evaluate claims and renders informed determination.
• Collaborates with other departments, such as claims processing, utilization management, provider relations and/or legal, to gather information and resolve complex cases.
• Draft 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.
• Maintain accurate and detailed records of all appeal activities, including case notes, correspondence, and final determinations.
• Escalate issues to Senior Management as appropriate.
• Responsible for drafting case files to be shared with the IRE.
• Stay up-to-date on changes in Medicare regulations, plan policies, and coding guidelines.
• Participate in ongoing training and development opportunities to enhance knowledge and skills.
• Participate in audit readiness and reviews.
• Contribute to the development and maintenance of customer services policy, procedures, internal desk manuals and workflows in support of appeals needs.
• Support use of knowledge management tools, including new workflows, and troubleshoot 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

• 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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