Job Description

The challenges of affordable healthcare continue to create new opportunities. Elderplan and HomeFirst, our Medicare and Medicaid managed care health plans, are outstanding examples of how we are expanding services in response to our patients' and members' needs. These high-quality healthcare plans are designed to help keep people independent and living life on their own terms.

As a support to the A&G Fair Hearing team, the A&G Fair Hearing Specialist serves a liaison between the Plan, OTDA, IAHO, members, and delegated vendors to effectively coordinate telephonic and in-person fair hearings. The position requires excellent communication, time management, and organizational skills to facilitate the timely gathering of documentation, communication between responsible parties, scheduling of fair hearings, documentation of fair hearing status and outcomes, and management calendars.

• Act as a liaison to provide timely responses and coordination for external reviews including, NYS Fair Hearing, and NYS DFS External Appeal, Maximum Federal, QIO, IAHO, and Fair Hearing.
• Receives and processes Fair Hearing requests/documentation.
• Maintains accurate case tracking and outcome data for all Fair Hearing cases through timely entry into the appeals & grievance software system.
• Accurate and timely data entry support as defined by departmental workflows.
• Identify, triage, categorize and route all documents that are received by the Appeals & Grievances Department.
• Processes AOR and WOL requests in accordance with SDOH and CMS regulations.
• Participates in scheduled team meetings.

• High School Diploma required Bachelor; Associate degree preferred.
• Two-year prior managed care experience required; Prior experience in a health care setting preferred.
• Familiarity with appeals and/or fair hearings.
• Telephone, Fax, Email, Scanner, Microsoft Word, Excel, PowerPoint, and capacity to learn other programs as assigned.
• Excellent written and oral communication skills.
• Good analytical abilities.
• Ability to be empathetic and understanding.
• Ability to handle confidential aspects of the position.
• Ability to work closely with different professionals as part of an interdisciplinary health care team.
• Good customer service skills.
• Ability to set priorities.
• Appropriately allocate resources, maximizes efficiency, and contain costs.
• Ability to work independently while recognizing issues having a departmental or organizational impact.
• Assess members needs and identify opportunities for recommending alternative levels of care.
• Ability to maintain collegial relationships and work in an interdisciplinary team environment.

MJHS

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