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Home › Companies › 11234a05 Dd20 44aa 9b1f Ca7bb9f6eba3 19000101 000001 › UM Appeals Specialist (Hybrid)

UM Appeals Specialist (Hybrid)

11234a05 Dd20 44aa 9b1f Ca7bb9f6eba3 19000101 000001 · Gastonia, NC, US, Gastonia, NC · Hybrid · Active · ADP Workforce Now Recruiting

Job facts

FieldValue
Company11234a05 Dd20 44aa 9b1f Ca7bb9f6eba3 19000101 000001
TitleUM Appeals Specialist (Hybrid)
Normalized title-
Department / team-
LocationGastonia, NC, United States
Work modelHybrid / Hybrid
Employment typeFull Time
Salary-
Statusactive
ATS providerADP Workforce Now Recruiting
Posted / first seen2026-05-28 / 2026-05-31
Changed / last seen2026-06-06 / 2026-06-06

Related slices

PageWhat it containsOpen
Company jobsActive postings from 11234a05 Dd20 44aa 9b1f Ca7bb9f6eba3 19000101 000001.Open
Company breakdownsRole, location, ATS, and work model facets for this company.Open
ATS provider jobsActive postings observed through ADP Workforce Now Recruiting.Open
Provider filtered searchThe same provider as a filtered job collection.Open
City jobsActive postings in Gastonia.Open
Work model jobsActive Hybrid postings.Open
Lifecycle eventsOpen, update, close, and reopen events for this posting.Open
Original postingCanonical source or apply URL captured from the ATS.Open

Linked records

Company11234a05 Dd20 44aa 9b1f Ca7bb9f6eba3 19000101 000001
Source255a48bf-6d53-42f4-abe2-2e15155d1f67
ATS providerADP Workforce Now Recruiting

Description

Competitive Compensation & Benefits Package! Position eligible for – Annual incentive bonus plan Medical, dental, and vision insurance with low deductible/low cost health plan Generous vacation and sick time accrual 12 paid holidays State Retirement (pension plan) 401(k) Plan with employer match Company paid life and disability insurance Wellness Programs Public Service Loan Forgiveness Qualifying Employer See attachment for additional details. Office Location: Available for the Gastonia, NC location. Hybrid (must work in the office 2 days per week). Projected Hiring Range : Depending on Experience Closing Date : Open Until Filled Primary Purpose of Position: This position is responsible for implementing and supporting the LME/MCO Medicaid and State appeals process. Role and Responsibilities: Implementation of MCO Medicaid and non-Medicaid Appeals Processes: Preparing, proofreading and verifying the accuracy of the LME/MCO notification letters to members/recipients/legal guardian/legal representatives and providers of reductions, suspensions, terminations or denials of services Assisting members/recipients, legal guardians and/or legal representatives in completing appeal requests for the agency Following federal, state and organizational policies Receive, track and follow individual authorization appeals from initiation to completion Work collaboratively with members/recipients/ legal guardian/legal representatives, providers, stakeholders, agency staff and others as necessary to ensure due process of authorization appeals Monitor the assignment of the local reconsideration review process for each appeal Timely documentation of all contacts with member/recipient/guardian, reviewer and providers; and establish and maintain the denial and appeals records Additional duties as needed to support and/or provide oversight of the appeals process in clinical operations and other organizational departments as deemed applicable Educate: Provide education, support and information to member/recipient, legal guardians, legal representatives and providers concerning and during the appeals process Answer questions about appeals process and assist member/recipient, legal guardians, and legal representatives in completing appeals forms (Medicaid & Non-Medicaid) Liaison: Serves as a staff liaison for all member/recipient, legal guardians, legal representative, providers, community stakeholders and the agency staff regarding all adverse events Responds to questions regarding authorization appeals in a timely manner Misc: Uses tact and diplomacy in communication with members/recipients, legal guardians, legal representatives, providers and others while working through the appeals process Effectively works with others to ensure timeliness of appeals process Appropriately responds to or directs questions/concerns and promotes a positive work environment. Participates in a telephone workgroup rotation to address calls received in the Appeals department. Other duties as assigned by Supervisor. Knowledge, Skills and Abilities: Knowledge of Federal and State regulations on behavioral healthcare denials and appeals processes National Accreditation knowledge specific to organization Knowledge of medical records practices and recordkeeping practices, including electronic records and imaging/scanning processes Knowledge in preparation for legal proceedings including mediation, administrative law courts and other legal processes Knowledge of agency policies and procedures that pertain to duties Knowledge of DMA and Division contracts specific to organization Knowledge of service definitions and DMA clinical policy Proficiency in Microsoft Office products (Word, Excel, Outlook, PowerPoint, etc.) Ability to organize multiple tasks and priorities and to effectively manage numerous details Ability to effectively and accurately manage projects from start to finish Ability to understand and adhere to amendments and priorities at the State, Federal, Accreditation or contract level Education and Experience Required: Bachelor’s Degree and two (2) years of Human Services/healthcare experience or a comprehensive combination of education and experience may be accepted. Education and Experience Preferred: A Qualified Professional (QP) with IDD/BH, Pharmacy and/or Physical Health/Medical experience is preferred. Licensure/Certification Requirements: None Required

Full job record

Job ID3739238ee2554fc88fcc3388b62e757d9bc7e1ae
Org IDdd48cc4f-1c55-49be-bfea-261bc9f09865
Source ID255a48bf-6d53-42f4-abe2-2e15155d1f67
Board ID255a48bf-6d53-42f4-abe2-2e15155d1f67
Provideradp_workforcenow
Provider Job Key562923
TitleUM Appeals Specialist (Hybrid)
Normalized Title—
Statusactive
Activeyes
Location TextGastonia, NC, US, Gastonia, NC
Department—
Team—
Employment Typefull_time
Workplace Typehybrid
Remote Policyhybrid
CountryUnited States
RegionNC
CityGastonia
Salary Raw—
Salary Min—
Salary Max—
Salary Currency—
Salary Period—
Source URLhttps://workforcenow.adp.com/mascsr/default/mdf/recruitment/recruitment.html?cid=11234a05-dd20-44aa-9b1f-ca7bb9f6eba3&ccId=19000101_000001&lang=en_US&type=JS&jobId=562923&jwId=9201587164532_1
Apply URLhttps://workforcenow.adp.com/mascsr/default/mdf/recruitment/recruitment.html?cid=11234a05-dd20-44aa-9b1f-ca7bb9f6eba3&ccId=19000101_000001&lang=en_US&type=JS&jobId=562923&jwId=9201587164532_1
First Seen At2026-05-31 18:23:05Z
Last Seen At2026-06-06 13:21:05Z
Last Checked At2026-06-06 13:21:05Z
Last Changed At2026-06-06 13:21:05Z
Inactive At—
Source Posted At2026-05-28 17:45:00Z
Source Updated At—
Raw Payload Uris3://job-postings-prod-raw-590183727216/raw/provider=adp_workforcenow/board=11234a05-dd20-44aa-9b1f-ca7bb9f6eba3|19000101_000001/date=2026-06-06/2026-06-06T13-21-04-525Z-d17d6db80861dba3cdb7765e2a90aedaaa582a84d9b2da40e9a66c0d7f1a2c2f.json
Event Fields
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  "last_changed_at": "2026-06-06T13:21:05.385Z",
  "active_status": "active"
}
Parsed Structured
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  },
  "remote_policy": "hybrid",
  "salary_period": null,
  "workplace_type": "hybrid",
  "salary_currency": null
}
Extensions
{}
Native Structured
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    "requisitionDescription": "<div><div><div><strong style='box-sizing: border-box; outline: none; --tw-shadow: 0 0 transparent; --tw-ring-inset: var(--tw-empty, ); --tw-ring-offset-width: 0px; --tw-ring-offset-color: #fff; --tw-ring-color: rgba(59,130,246,0.5); --tw-ring-offset-shadow: 0 0 transparent; --tw-ring-shadow: 0 0 transparent; color: rgb(38, 35, 33); font-family: Circular, -apple-system, BlinkMacSystemFont, \"Segoe UI\", Roboto, Oxygen, Ubuntu, Cantarell, \"Fira Sans\", \"Droid Sans\", \"Helvetica Neue\", sans-serif; font-size: 16px; font-style: normal; font-variant-ligatures: normal; font-variant-caps: normal; letter-spacing: normal; orphans: 2; text-align: start; text-indent: 0px; text-transform: none; widows: 2; word-spacing: 0px; -webkit-text-stroke-width: 0px; white-space: normal; text-decoration-thickness: initial; text-decoration-style: initial; text-decoration-color: initial; font-weight: 700; background-color: rgb(255, 255, 255);' data-pasted=\"true\"><em style=\"box-sizing: border-box; outline: none; --tw-shadow: 0 0 transparent; --tw-ring-inset: var(--tw-empty, ); --tw-ring-offset-width: 0px; --tw-ring-offset-color: #fff; --tw-ring-color: rgba(59,130,246,0.5); --tw-ring-offset-shadow: 0 0 transparent; --tw-ring-shadow: 0 0 transparent;\"><span style=\"box-sizing: border-box; outline: none; --tw-shadow: 0 0 transparent; --tw-ring-inset: var(--tw-empty, ); --tw-ring-offset-width: 0px; --tw-ring-offset-color: #fff; --tw-ring-color: rgba(59,130,246,0.5); --tw-ring-offset-shadow: 0 0 transparent; --tw-ring-shadow: 0 0 transparent; font-size: 16px; font-family: tahoma, sans-serif;\">Competitive Compensation &amp; Benefits Package! &nbsp;</span></em></strong><p style='box-sizing: border-box; outline: none; --tw-shadow: 0 0 transparent; --tw-ring-inset: var(--tw-empty, ); --tw-ring-offset-width: 0px; --tw-ring-offset-color: #fff; --tw-ring-color: rgba(59,130,246,0.5); --tw-ring-offset-shadow: 0 0 transparent; --tw-ring-shadow: 0 0 transparent; margin: 0in 0in 0.0001pt; line-height: var(--line-height-base); color: rgb(38, 35, 33); font-size: 16px; font-style: normal; font-variant-ligatures: normal; font-variant-caps: normal; font-weight: 400; letter-spacing: normal; orphans: 2; text-align: start; text-indent: 0px; text-transform: none; widows: 2; word-spacing: 0px; -webkit-text-stroke-width: 0px; white-space: normal; text-decoration-thickness: initial; text-decoration-style: initial; text-decoration-color: initial; background-color: rgb(255, 255, 255); font-family: \"Times New Roman\", serif;'><span style=\"box-sizing: border-box; outline: none; --tw-shadow: 0 0 transparent; --tw-ring-inset: var(--tw-empty, ); --tw-ring-offset-width: 0px; --tw-ring-offset-color: #fff; --tw-ring-color: rgba(59,130,246,0.5); --tw-ring-offset-shadow: 0 0 transparent; --tw-ring-shadow: 0 0 transparent; font-size: 16px; font-family: tahoma, sans-serif;\">Position eligible for &ndash;&nbsp;</span></p><ul style='box-sizing: border-box; outline: none; --tw-shadow: 0 0 transparent; --tw-ring-inset: var(--tw-empty, ); --tw-ring-offset-width: 0px; --tw-ring-offset-color: #fff; --tw-ring-color: rgba(59,130,246,0.5); --tw-ring-offset-shadow: 0 0 transparent; --tw-ring-shadow: 0 0 transparent; color: rgb(38, 35, 33); font-family: Circular, -apple-system, BlinkMacSystemFont, \"Segoe UI\", Roboto, Oxygen, Ubuntu, Cantarell, \"Fira Sans\", \"Droid Sans\", \"Helvetica Neue\", sans-serif; font-size: 16px; font-style: normal; font-variant-ligatures: normal; font-variant-caps: normal; font-weight: 400; letter-spacing: normal; orphans: 2; text-align: start; text-indent: 0px; text-transform: none; widows: 2; word-spacing: 0px; -webkit-text-stroke-width: 0px; white-space: normal; text-decoration-thickness: initial; text-decoration-style: initial; text-decoration-color: initial; margin-top: 0px; margin-bottom: 10px; line-height: 1.42857; background-color: rgb(255, 255, 255); list-style-type: disc; margin-left: 0in;'><li style=\"box-sizing: border-box; outline: none; --tw-shadow: 0 0 transparent; --tw-ring-inset: var(--tw-empty, ); --tw-ring-offset-width: 0px; --tw-ring-offset-color: #fff; --tw-ring-color: rgba(59,130,246,0.5); --tw-ring-offset-shadow: 0 0 transparent; --tw-ring-shadow: 0 0 transparent; font-family: tahoma, sans-serif; font-size: 16px;\">Annual incentive bonus plan</li><li style=\"box-sizing: border-box; outline: none; --tw-shadow: 0 0 transparent; --tw-ring-inset: var(--tw-empty, ); --tw-ring-offset-width: 0px; --tw-ring-offset-color: #fff; --tw-ring-color: rgba(59,130,246,0.5); --tw-ring-offset-shadow: 0 0 transparent; --tw-ring-shadow: 0 0 transparent; font-family: tahoma, sans-serif; font-size: 16px;\">Medical, dental, and vision insurance with low deductible/low cost health plan</li><li style=\"box-sizing: border-box; outline: none; --tw-shadow: 0 0 transparent; --tw-ring-inset: var(--tw-empty, ); --tw-ring-offset-width: 0px; --tw-ring-offset-color: #fff; --tw-ring-color: rgba(59,130,246,0.5); --tw-ring-offset-shadow: 0 0 transparent; --tw-ring-shadow: 0 0 transparent; font-family: tahoma, sans-serif; font-size: 16px;\">Generous vacation and sick time accrual</li><li style=\"box-sizing: border-box; outline: none; --tw-shadow: 0 0 transparent; --tw-ring-inset: var(--tw-empty, ); --tw-ring-offset-width: 0px; --tw-ring-offset-color: #fff; --tw-ring-color: rgba(59,130,246,0.5); --tw-ring-offset-shadow: 0 0 transparent; --tw-ring-shadow: 0 0 transparent; font-family: tahoma, sans-serif; font-size: 16px;\">12 paid holidays</li><li style=\"box-sizing: border-box; outline: none; --tw-shadow: 0 0 transparent; --tw-ring-inset: var(--tw-empty, ); --tw-ring-offset-width: 0px; --tw-ring-offset-color: #fff; --tw-ring-color: rgba(59,130,246,0.5); --tw-ring-offset-shadow: 0 0 transparent; --tw-ring-shadow: 0 0 transparent; font-family: tahoma, sans-serif; font-size: 16px;\">State Retirement (pension plan)</li><li style=\"box-sizing: border-box; outline: none; --tw-shadow: 0 0 transparent; --tw-ring-inset: var(--tw-empty, ); --tw-ring-offset-width: 0px; --tw-ring-offset-color: #fff; --tw-ring-color: rgba(59,130,246,0.5); --tw-ring-offset-shadow: 0 0 transparent; --tw-ring-shadow: 0 0 transparent; font-family: tahoma, sans-serif; font-size: 16px;\">401(k) Plan with employer match</li><li style=\"box-sizing: border-box; outline: none; --tw-shadow: 0 0 transparent; --tw-ring-inset: var(--tw-empty, ); --tw-ring-offset-width: 0px; --tw-ring-offset-color: #fff; --tw-ring-color: rgba(59,130,246,0.5); --tw-ring-offset-shadow: 0 0 transparent; --tw-ring-shadow: 0 0 transparent; font-family: tahoma, sans-serif; font-size: 16px;\">Company paid life and disability insurance</li><li style=\"box-sizing: border-box; outline: none; --tw-shadow: 0 0 transparent; --tw-ring-inset: var(--tw-empty, ); --tw-ring-offset-width: 0px; --tw-ring-offset-color: #fff; --tw-ring-color: rgba(59,130,246,0.5); --tw-ring-offset-shadow: 0 0 transparent; --tw-ring-shadow: 0 0 transparent; font-family: tahoma, sans-serif; font-size: 16px;\">Wellness Programs</li><li style=\"box-sizing: border-box; outline: none; --tw-shadow: 0 0 #0000; --tw-ring-inset: var(--tw-empty,/*!*/ /*!*/); --tw-ring-offset-width: 0px; --tw-ring-offset-color: #fff; --tw-ring-color: rgba(59,130,246,.5); --tw-ring-offset-shadow: 0 0 #0000; --tw-ring-shadow: 0 0 #0000; font-family: tahoma, sans-serif; font-size: 16px;\">Public Service Loan Forgiveness Qualifying Employer</li></ul><p style=\"box-sizing: border-box; outline: none; --tw-shadow: 0 0 transparent; --tw-ring-inset: var(--tw-empty, ); --tw-ring-offset-width: 0px; --tw-ring-offset-color: #fff; --tw-ring-color: rgba(59,130,246,0.5); --tw-ring-offset-shadow: 0 0 transparent; --tw-ring-shadow: 0 0 transparent; margin: 0in; line-height: var(--line-height-base); color: rgb(38, 35, 33); font-style: normal; font-variant-ligatures: normal; font-variant-caps: normal; font-weight: 400; letter-spacing: normal; orphans: 2; text-align: start; text-indent: 0px; text-transform: none; widows: 2; word-spacing: 0px; -webkit-text-stroke-width: 0px; white-space: normal; text-decoration-thickness: initial; text-decoration-style: initial; text-decoration-color: initial; background-color: rgb(255, 255, 255); font-size: 13px; font-family: Calibri, sans-serif;\"><span style=\"box-sizing: border-box; outline: none; --tw-shadow: 0 0 transparent; --tw-ring-inset: var(--tw-empty, ); --tw-ring-offset-width: 0px; --tw-ring-offset-color: #fff; --tw-ring-color: rgba(59,130,246,0.5); --tw-ring-offset-shadow: 0 0 transparent; --tw-ring-shadow: 0 0 transparent; font-size: 16px; font-family: tahoma, sans-serif;\">See attachment for additional details.&nbsp;</span></p><p style=\"box-sizing: border-box; outline: none; --tw-shadow: 0 0 transparent; --tw-ring-inset: var(--tw-empty, ); --tw-ring-offset-width: 0px; --tw-ring-offset-color: #fff; --tw-ring-color: rgba(59,130,246,0.5); --tw-ring-offset-shadow: 0 0 transparent; --tw-ring-shadow: 0 0 transparent; margin: 0in; line-height: var(--line-height-base); color: rgb(38, 35, 33); font-style: normal; font-variant-ligatures: normal; font-variant-caps: normal; font-weight: 400; letter-spacing: normal; orphans: 2; text-align: start; text-indent: 0px; text-transform: none; widows: 2; word-spacing: 0px; -webkit-text-stroke-width: 0px; white-space: normal; text-decoration-thickness: initial; text-decoration-style: initial; text-decoration-color: initial; background-color: rgb(255, 255, 255); font-size: 13px; font-family: Calibri, sans-serif;\"><span style=\"box-sizing: border-box; outline: none; --tw-shadow: 0 0 transparent; --tw-ring-inset: var(--tw-empty, ); --tw-ring-offset-width: 0px; --tw-ring-offset-color: #fff; --tw-ring-color: rgba(59,130,246,0.5); --tw-ring-offset-shadow: 0 0 transparent; --tw-ring-shadow: 0 0 transparent; font-family: tahoma, sans-serif; font-size: 16px;\"><strong style=\"box-sizing: border-box; outline: none; --tw-shadow: 0 0 transparent; --tw-ring-inset: var(--tw-empty, ); --tw-ring-offset-width: 0px; --tw-ring-offset-color: #fff; --tw-ring-color: rgba(59,130,246,0.5); --tw-ring-offset-shadow: 0 0 transparent; --tw-ring-shadow: 0 0 transparent; font-weight: 700;\"><span style=\"box-sizing: border-box; outline: none; --tw-shadow: 0 0 transparent; --tw-ring-inset: var(--tw-empty, ); --tw-ring-offset-width: 0px; --tw-ring-offset-color: #fff; --tw-ring-color: rgba(59,130,246,0.5); --tw-ring-offset-shadow: 0 0 transparent; --tw-ring-shadow: 0 0 transparent; color: rgb(68, 68, 68);\">&nbsp;</span></strong></span></p><p style=\"box-sizing: border-box; outline: none; --tw-shadow: 0 0 transparent; --tw-ring-inset: var(--tw-empty, ); --tw-ring-offset-width: 0px; --tw-ring-offset-color: #fff; --tw-ring-color: rgba(59,130,246,0.5); --tw-ring-offset-shadow: 0 0 transparent; --tw-ring-shadow: 0 0 transparent; margin: 0in; line-height: var(--line-height-base); color: rgb(38, 35, 33); font-style: normal; font-variant-ligatures: normal; font-variant-caps: normal; font-weight: 400; letter-spacing: normal; orphans: 2; text-align: start; text-indent: 0px; text-transform: none; widows: 2; word-spacing: 0px; -webkit-text-stroke-width: 0px; white-space: normal; text-decoration-thickness: initial; text-decoration-style: initial; text-decoration-color: initial; background-color: rgb(255, 255, 255); font-size: 13px; font-family: Calibri, sans-serif;\"><span style=\"box-sizing: border-box; outline: none; --tw-shadow: 0 0 transparent; --tw-ring-inset: var(--tw-empty, ); --tw-ring-offset-width: 0px; --tw-ring-offset-color: #fff; --tw-ring-color: rgba(59,130,246,0.5); --tw-ring-offset-shadow: 0 0 transparent; --tw-ring-shadow: 0 0 transparent; font-family: tahoma, sans-serif; font-size: 16px;\"><strong style=\"box-sizing: border-box; outline: none; --tw-shadow: 0 0 transparent; --tw-ring-inset: var(--tw-empty, ); --tw-ring-offset-width: 0px; --tw-ring-offset-color: #fff; --tw-ring-color: rgba(59,130,246,0.5); --tw-ring-offset-shadow: 0 0 transparent; --tw-ring-shadow: 0 0 transparent; font-weight: 700;\">Office Location:</strong></span><span style=\"box-sizing: border-box; outline: none; --tw-shadow: 0 0 transparent; --tw-ring-inset: var(--tw-empty, ); --tw-ring-offset-width: 0px; --tw-ring-offset-color: #fff; --tw-ring-color: rgba(59,130,246,0.5); --tw-ring-offset-shadow: 0 0 transparent; --tw-ring-shadow: 0 0 transparent; font-size: 16px; font-family: tahoma, sans-serif;\">&nbsp; Available for the Gastonia, NC location. &nbsp;Hybrid (must work in the office 2 days per week).</span></p><p style=\"box-sizing: border-box; outline: none; --tw-shadow: 0 0 transparent; --tw-ring-inset: var(--tw-empty, ); --tw-ring-offset-width: 0px; --tw-ring-offset-color: #fff; --tw-ring-color: rgba(59,130,246,0.5); --tw-ring-offset-shadow: 0 0 transparent; --tw-ring-shadow: 0 0 transparent; margin: 0in; line-height: var(--line-height-base); color: rgb(38, 35, 33); font-style: normal; font-variant-ligatures: normal; font-variant-caps: normal; font-weight: 400; letter-spacing: normal; orphans: 2; text-align: start; text-indent: 0px; text-transform: none; widows: 2; word-spacing: 0px; -webkit-text-stroke-width: 0px; white-space: normal; text-decoration-thickness: initial; text-decoration-style: initial; text-decoration-color: initial; background-color: rgb(255, 255, 255); font-size: 13px; font-family: Calibri, sans-serif;\"><span style=\"box-sizing: border-box; outline: none; --tw-shadow: 0 0 transparent; --tw-ring-inset: var(--tw-empty, ); --tw-ring-offset-width: 0px; --tw-ring-offset-color: #fff; --tw-ring-color: rgba(59,130,246,0.5); --tw-ring-offset-shadow: 0 0 transparent; --tw-ring-shadow: 0 0 transparent; font-family: tahoma, sans-serif; font-size: 16px;\"><strong style=\"box-sizing: border-box; outline: none; --tw-shadow: 0 0 transparent; --tw-ring-inset: var(--tw-empty, ); --tw-ring-offset-width: 0px; --tw-ring-offset-color: #fff; --tw-ring-color: rgba(59,130,246,0.5); --tw-ring-offset-shadow: 0 0 transparent; --tw-ring-shadow: 0 0 transparent; font-weight: 700;\"><span style=\"box-sizing: border-box; outline: none; --tw-shadow: 0 0 transparent; --tw-ring-inset: var(--tw-empty, ); --tw-ring-offset-width: 0px; --tw-ring-offset-color: #fff; --tw-ring-color: rgba(59,130,246,0.5); --tw-ring-offset-shadow: 0 0 transparent; --tw-ring-shadow: 0 0 transparent; color: rgb(68, 68, 68);\">Projected Hiring Range</span></strong></span><span style=\"box-sizing: border-box; outline: none; --tw-shadow: 0 0 transparent; --tw-ring-inset: var(--tw-empty, ); --tw-ring-offset-width: 0px; --tw-ring-offset-color: #fff; --tw-ring-color: rgba(59,130,246,0.5); --tw-ring-offset-shadow: 0 0 transparent; --tw-ring-shadow: 0 0 transparent; font-size: 16px; font-family: tahoma, sans-serif; color: rgb(68, 68, 68);\">: &nbsp;Depending on Experience<br style=\"box-sizing: border-box; outline: none; --tw-shadow: 0 0 transparent; --tw-ring-inset: var(--tw-empty, ); --tw-ring-offset-width: 0px; --tw-ring-offset-color: #fff; --tw-ring-color: rgba(59,130,246,0.5); --tw-ring-offset-shadow: 0 0 transparent; --tw-ring-shadow: 0 0 transparent;\"></span><span style=\"box-sizing: border-box; outline: none; --tw-shadow: 0 0 transparent; --tw-ring-inset: var(--tw-empty, ); --tw-ring-offset-width: 0px; --tw-ring-offset-color: #fff; --tw-ring-color: rgba(59,130,246,0.5); --tw-ring-offset-shadow: 0 0 transparent; --tw-ring-shadow: 0 0 transparent; font-family: tahoma, sans-serif; font-size: 16px;\"><strong style=\"box-sizing: border-box; outline: none; --tw-shadow: 0 0 transparent; --tw-ring-inset: var(--tw-empty, ); --tw-ring-offset-width: 0px; --tw-ring-offset-color: #fff; --tw-ring-color: rgba(59,130,246,0.5); --tw-ring-offset-shadow: 0 0 transparent; --tw-ring-shadow: 0 0 transparent; font-weight: 700;\"><span style=\"box-sizing: border-box; outline: none; --tw-shadow: 0 0 transparent; --tw-ring-inset: var(--tw-empty, ); --tw-ring-offset-width: 0px; --tw-ring-offset-color: #fff; --tw-ring-color: rgba(59,130,246,0.5); --tw-ring-offset-shadow: 0 0 transparent; --tw-ring-shadow: 0 0 transparent; color: rgb(68, 68, 68);\">Closing Date</span></strong></span><span style=\"box-sizing: border-box; outline: none; --tw-shadow: 0 0 transparent; --tw-ring-inset: var(--tw-empty, ); --tw-ring-offset-width: 0px; --tw-ring-offset-color: #fff; --tw-ring-color: rgba(59,130,246,0.5); --tw-ring-offset-shadow: 0 0 transparent; --tw-ring-shadow: 0 0 transparent; font-size: 16px; font-family: tahoma, sans-serif; color: rgb(68, 68, 68);\">: &nbsp;</span><span style=\"box-sizing: border-box; outline: none; --tw-shadow: 0 0 transparent; --tw-ring-inset: var(--tw-empty, ); --tw-ring-offset-width: 0px; --tw-ring-offset-color: #fff; --tw-ring-color: rgba(59,130,246,0.5); --tw-ring-offset-shadow: 0 0 transparent; --tw-ring-shadow: 0 0 transparent; font-family: tahoma, sans-serif; font-size: 16px;\"><strong style=\"box-sizing: border-box; outline: none; --tw-shadow: 0 0 transparent; --tw-ring-inset: var(--tw-empty, ); --tw-ring-offset-width: 0px; --tw-ring-offset-color: #fff; --tw-ring-color: rgba(59,130,246,0.5); --tw-ring-offset-shadow: 0 0 transparent; --tw-ring-shadow: 0 0 transparent; font-weight: 700;\"><span style=\"box-sizing: border-box; outline: none; --tw-shadow: 0 0 transparent; --tw-ring-inset: var(--tw-empty, ); --tw-ring-offset-width: 0px; --tw-ring-offset-color: #fff; --tw-ring-color: rgba(59,130,246,0.5); --tw-ring-offset-shadow: 0 0 transparent; --tw-ring-shadow: 0 0 transparent; color: blue;\">Open Until Filled</span></strong></span></p><p style='box-sizing: border-box; outline: none; --tw-shadow: 0 0 #0000; --tw-ring-inset: var(--tw-empty,/*!*/ /*!*/); --tw-ring-offset-width: 0px; --tw-ring-offset-color: #fff; --tw-ring-color: rgba(59,130,246,.5); --tw-ring-offset-shadow: 0 0 #0000; --tw-ring-shadow: 0 0 #0000; margin-top: 0px; margin-bottom: 1rem; line-height: var(--line-height-base); color: rgb(38, 35, 33); font-family: Circular, -apple-system, BlinkMacSystemFont, \"Segoe UI\", Roboto, Oxygen, Ubuntu, Cantarell, \"Fira Sans\", \"Droid Sans\", \"Helvetica Neue\", sans-serif; font-size: 16px; font-style: normal; font-variant-ligatures: normal; font-variant-caps: normal; font-weight: 400; letter-spacing: normal; orphans: 2; text-align: start; text-indent: 0px; text-transform: none; widows: 2; word-spacing: 0px; -webkit-text-stroke-width: 0px; white-space: normal; background-color: rgb(255, 255, 255); text-decoration-thickness: initial; text-decoration-style: initial; text-decoration-color: initial;'><br style=\"box-sizing: border-box; outline: none; --tw-shadow: 0 0 #0000; --tw-ring-inset: var(--tw-empty,/*!*/ /*!*/); --tw-ring-offset-width: 0px; --tw-ring-offset-color: #fff; --tw-ring-color: rgba(59,130,246,.5); --tw-ring-offset-shadow: 0 0 #0000; --tw-ring-shadow: 0 0 #0000; color: rgb(38, 35, 33); font-family: Circular, -apple-system, BlinkMacSystemFont, &quot;Segoe UI&quot;, Roboto, Oxygen, Ubuntu, Cantarell, &quot;Fira Sans&quot;, &quot;Droid Sans&quot;, &quot;Helvetica Neue&quot;, sans-serif; font-size: 16px; font-style: normal; font-variant-ligatures: normal; font-variant-caps: normal; font-weight: 400; letter-spacing: normal; orphans: 2; text-align: start; text-indent: 0px; text-transform: none; widows: 2; word-spacing: 0px; -webkit-text-stroke-width: 0px; white-space: normal; background-color: rgb(255, 255, 255); text-decoration-thickness: initial; text-decoration-style: initial; text-decoration-color: initial;\"></p><p><strong><span style=\"font-family: tahoma, sans-serif; font-size: 16px;\">Primary Purpose of Position: </span></strong><span style=\"font-family: tahoma, sans-serif; font-size: 16px;\">This position is responsible for implementing and supporting the LME/MCO Medicaid and State appeals process. &nbsp;</span></p><p><span style=\"font-family: tahoma, sans-serif; font-size: 16px;\"><br></span></p><p><span style=\"font-family: tahoma, sans-serif; font-size: 16px;\"><strong>Role and Responsibilities:</strong> &nbsp;</span></p><p><span style=\"font-family: tahoma, sans-serif; font-size: 16px;\">Implementation of MCO Medicaid and non-Medicaid Appeals Processes: &nbsp;</span></p><ul><li style=\"font-family: tahoma, sans-serif; font-size: 16px;\">Preparing, proofreading and verifying the accuracy of the LME/MCO notification letters to members/recipients/legal guardian/legal representatives and providers of reductions, suspensions, terminations or denials of services</li><li style=\"font-family: tahoma, sans-serif; font-size: 16px;\">Assisting members/recipients, legal guardians and/or legal representatives in completing appeal requests for the agency</li><li style=\"font-family: tahoma, sans-serif; font-size: 16px;\">Following federal, state and organizational policies</li><li style=\"font-family: tahoma, sans-serif; font-size: 16px;\">Receive, track and follow individual authorization appeals from initiation to completion</li><li style=\"font-family: tahoma, sans-serif; font-size: 16px;\">Work collaboratively with members/recipients/ legal guardian/legal representatives, providers, stakeholders, agency staff and others as necessary to ensure due process of authorization appeals</li><li style=\"font-family: tahoma, sans-serif; font-size: 16px;\">Monitor the assignment of the local reconsideration review process for each appeal</li><li style=\"font-family: tahoma, sans-serif; font-size: 16px;\">Timely documentation of all contacts with member/recipient/guardian, reviewer and providers; and establish and maintain the denial and appeals records</li><li style=\"font-family: tahoma, sans-serif; font-size: 16px;\">Additional duties as needed to support and/or provide oversight of the appeals process in clinical operations and other organizational departments as deemed applicable</li></ul><p><span style=\"font-family: tahoma, sans-serif; font-size: 16px;\">Educate: &nbsp;</span></p><ul><li style=\"font-family: tahoma, sans-serif; font-size: 16px;\">Provide education, support and information to member/recipient, legal guardians, legal representatives and providers concerning and during the appeals process</li><li style=\"font-family: tahoma, sans-serif; font-size: 16px;\">Answer questions about appeals process and assist member/recipient, legal guardians, and legal representatives in completing appeals forms (Medicaid &amp; Non-Medicaid)</li></ul><p><span style=\"font-family: tahoma, sans-serif; font-size: 16px;\">Liaison: &nbsp;</span></p><ul><li style=\"font-family: tahoma, sans-serif; font-size: 16px;\">Serves as a staff liaison for all member/recipient, legal guardians, legal representative, providers, community stakeholders and the agency staff regarding all adverse events</li><li style=\"font-family: tahoma, sans-serif; font-size: 16px;\">Responds to questions regarding authorization appeals in a timely manner</li></ul><p><span style=\"font-family: tahoma, sans-serif; font-size: 16px;\">Misc: &nbsp;</span></p><ul><li style=\"font-family: tahoma, sans-serif; font-size: 16px;\">Uses tact and diplomacy in communication with members/recipients, legal guardians, legal representatives, providers and others while working through the appeals process</li><li style=\"font-family: tahoma, sans-serif; font-size: 16px;\">Effectively works with others to ensure timeliness of appeals process</li><li style=\"font-family: tahoma, sans-serif; font-size: 16px;\">Appropriately responds to or directs questions/concerns and promotes a positive work environment.</li><li style=\"font-family: tahoma, sans-serif; font-size: 16px;\">Participates in a telephone workgroup rotation to address calls received in the Appeals department.</li><li style=\"font-family: tahoma, sans-serif; font-size: 16px;\">Other duties as assigned by Supervisor.</li></ul><p><span style=\"font-family: tahoma, sans-serif; font-size: 16px;\"><br></span></p><p><span style=\"font-family: tahoma, sans-serif; font-size: 16px;\"><strong>Knowledge, Skills and Abilities:</strong>&nbsp;</span></p><ul><li style=\"font-family: tahoma, sans-serif; font-size: 16px;\">Knowledge of Federal and State regulations on behavioral healthcare denials and appeals processes</li><li style=\"font-family: tahoma, sans-serif; font-size: 16px;\">National Accreditation knowledge specific to organization</li><li style=\"font-family: tahoma, sans-serif; font-size: 16px;\">Knowledge of medical records practices and recordkeeping practices, including electronic records and imaging/scanning processes</li><li style=\"font-family: tahoma, sans-serif; font-size: 16px;\">Knowledge in preparation for legal proceedings including mediation, administrative law courts and other legal processes</li><li style=\"font-family: tahoma, sans-serif; font-size: 16px;\">Knowledge of agency policies and procedures that pertain to duties</li><li style=\"font-family: tahoma, sans-serif; font-size: 16px;\">Knowledge of DMA and Division contracts specific to organization</li><li style=\"font-family: tahoma, sans-serif; font-size: 16px;\">Knowledge of service definitions and DMA clinical policy</li><li style=\"font-family: tahoma, sans-serif; font-size: 16px;\">Proficiency in Microsoft Office products (Word, Excel, Outlook, PowerPoint, etc.)</li><li style=\"font-family: tahoma, sans-serif; font-size: 16px;\">Ability to organize multiple tasks and priorities and to effectively manage numerous details</li><li style=\"font-family: tahoma, sans-serif; font-size: 16px;\">Ability to effectively and accurately manage projects from start to finish</li><li style=\"font-family: tahoma, sans-serif; font-size: 16px;\">Ability to understand and adhere to amendments and priorities at the State, Federal, Accreditation or contract level</li></ul><p><span style=\"font-family: tahoma, sans-serif; font-size: 16px;\"><br></span></p><p><span style=\"font-family: tahoma, sans-serif; font-size: 16px;\"><strong>Education and Experience Required:</strong> Bachelor&rsquo;s Degree and two (2) years of Human Services/healthcare experience or a comprehensive combination of education and experience may be accepted.&nbsp;</span></p><p><span style=\"font-family: tahoma, sans-serif; font-size: 16px;\"><strong>Education and Experience Preferred:</strong> A Qualified Professional (QP) with IDD/BH, Pharmacy and/or Physical Health/Medical experience is preferred. &nbsp;</span></p><p><span style=\"font-family: tahoma, sans-serif; font-size: 16px;\"><strong>Licensure/Certification Requirements:</strong> None Required&nbsp;</span></p><p><br></p></div></div></div>\n",
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