Appeals Consultant

[Legal Jobs]

Appeals Consultant
Category: Healthcare
Plan: TN-Blue Cross and Blue Shield of Tennessee
City: Chattanooga
State: TN
Type: Full Time

Description:To apply please visit our website at http://www.bcbst.com/about/careers/openings/
This position is responsible for coordination, monitoring and implementation of the highly regulated Medicare second level appeals process (reconsiderations) conducted by RiverTrust Solutions as a Qualified Independent Contractor (QIC) for the Centers for Medicare & Medicaid Services (CMS). The position is accountable to monitor and research regulatory issues governing Medicare appeals as well as appropriately apply the appropriate standards in accordance with the Code of Federal Regulations. The incumbent will also be accountable for writing Administrative Law Judge (ALJ) position papers, developing decision letter templates, and monitoring the quality of RiverTrust's decision letters.
The position is further challenged to improve the operating efficiency and quality of the reconsideration decision letter processes through the evaluation of workflow and audits, root cause analysis, trending, process improvement, reporting and effective utilization of resources. This position will interface directly with the Reconsiderations Manager and the Medical Director RiverTrust as well as other physician staff to obtain resolution of appeals and to provide education of CMS regulations and guidelines.

Functions
Conduct research, analyze and determine appropriate classification of appeal applying Medicare regulations and policies.
Respond to and process CMS reported complaints regarding reconsideration decisions collaboratively with appropriate internal departments and CMS.
Draft ALJ position papers in support of RiverTrust's reconsideration decisions on clinical, billing, and coding appeals.
Create templated language utilizing appropriate legal citations to be utilized by RiverTrust's adjudication staff.
Develop, coordinate, implement, and monitor procedures outlining the operational workflow of appeals.
Develop consistent CMS required reporting methodologies and maintain reports.
Advise management of the impact of CMS and regulatory changes related to appeals, as well as establish implementation plans as appropriate.
Track, monitor and trend appeals, and provide recommendations for quality improvement and increased operational efficiencies to management.
Initiate internal consulting with related functional departments in order to analyze workflow and make recommendations for process improvement.
Act as liaison to Quality Management related to appeals processes working collaboratively on quality improvement activities in accordance with regulatory and applicable accrediting body requirements.
Develop and administer a training program to educate internal areas of appeals requirements.
Provide legal advice or clinical expertise to Reconsideration Department or Medical Director in reviewing, researching, investigating, and resolving all types of appeals.
Represent RiverTrust's and CMS's position on interpretation of law and legislative intent in ALJ Hearing proceedings. Participate in ALJ proceedings and recommend CMS's participation if necessary.
Communicate with appropriate parties regarding appeals issues, implications, and decisions.
Research and resolve written CMS or ALJ complex or multi-issue provider appeals.
Uses pertinent data and facts to identify and solve a range of problems within area of expertise.
Ability to work independently.

Qualifications:Bachelor's in Liberal Arts discipline or Science in Nursing required.
Experience as Paralegal or Certified Nurse Legal Consultant would be preferred.
J.D. (Law) or Master's of Science in Nursing (M.S.N.) would be highly preferred
Legal training or significant clinical experience with demonstrated writing experience supported by the any of the following experiences is required: Three (3) years health care law experience or two years of specialized work experience performing legal research supporting Medicare claims and/or appeals processing and/or hearings.
Two years experience in quality management and continuous process improvement preferred.
Proven ability to plan, organize, and coordinate multiple projects related to operational workflow.
Exceptional level of independence, organization, verbal and written communication, professional interaction and human relation skills, as well as analytical skills required.
2+ yrs professional experience with MS Office Suite - Word, Outlook, and Excel is required.
Req Code: 0801108
Location: Chattanooga, TN, 37404, USA

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