The Appeals and Compliance Specialist is responsible for providing comprehensive responses in compliance with contract, regulatory and accreditation requirements pertaining to various product lines that encompasses services funded by MI Choice. Contact participants to gather information and communicate disposition of appeal. Conduct pertinent research to evaluate, respond to, and finalize appeal disposition. Represent AgeWays during external communication with participant and during the administrative hearing process. Works closely with the Compliance Officer and is an active member of the agency’s Special Investigative Unit (SIU). Conducts investigations related to reports of non-compliance, data mining, and program integrity activities. Ensures agency is adhering to the MI Choice contract and the Michigan Medicaid Provider Manual (MPM) requirements. Completes state forms and required reporting accurately and concisely.

Duties Include:

• Identify, support and maintain program compliance by conducting clinical and provider documentation review, interviews with staff, participants, providers, family members and/or others with knowledge of the complaint. Determining appropriateness of Medicaid payments and taking steps to refer the investigation to the state and/or to initiate education and payment collection processes.

• Internal Appeal / Chart Review to determine appropriate action was taken by the waiver agent in compliance with contractual, regulatory and accreditation guidelines. Review includes case record progress notes, assessments, person-centered service plans, and authorized services. Conducts investigation/s involving provision of service issues. Correspond with participants and their representatives to gather information and communicate disposition of case .

• Triages case inquiries, appeals, and prepares case files/packets for appeal hearings. Attend State Fair Hearings and provide testimony on rationale used for internal decisions to review boards, legal representatives, providers and regulatory agencies. The Reviewer must be able to explain decision rationale and connect it to MDHHS contract requirements.

• Collaborates with the Supervisor and/or applicable SME, to insure appropriate understanding of contract, regulatory, and accreditation standards. Communicate with other individuals as necessary, both internal and external to the agency prior to the completion of decision notice correspondence or investigative findings.

• Utilize established clinical criteria, MPM, MI Choice contract, other resources and clinical evidence to develop sound and well-supported appeal and investigation correspondence. Maintain current knowledge of internal policies and processes, accreditation standards, existing and new laws. Ensure forms and documents are up to date with current standards .

• Other duties as assigned (to view the entire job description, please select the "download" button).

Qualifications

QUALIFICATIONS:

• RN Candidates: Minimum Assoc. or Nursing Degree with current State of MI nursing license required.

• Candidates with Experience: Must have 2-4+ years of experience in an administrative clinical setting, including 1-2 years medicaid managed care appeals process & Health/Human Services.

• The ability to effectively interact with managers, other agency employees, program participants, community members, state and local governmental representatives and other stakeholders.

• Excellent interpersonal, communication, organizational, training, and investigative skills. The ability to conduct clinical case/documentation reviews, present findings and appeals recommendations. Effective time management skills, including the ability to meet deadlines.

• Knowledge of community based services and experience working with older adults or people with disabilities desired.

• MS Office Intermediate to Advanced.

OUR INDUSTRY-LEADING BENEFITS CONSISTS OF:

Choice of 3 excellent next to zero cost Medical Plans including Dental and Vision.

401K - Agency contributes 50% match up to first 6% contribution.

Fitness and Wellness programs.

Excellent PTO package- Minimum 4 weeks accrual for the first year.

Get 10 paid holidays and 3 floating.

Mileage reimbursed for business travel.

Work schedules consist of hybrid, community-based, or office-based.

Our recruiting team would love to hear from you today! Please complete our on-line application and submit your resume for immediate consideration. The Area Agency on Aging 1-B is an Equal Opportunity and Affirmative Action Employer.