Appeals Coordinator

Description:

Position title: Appeals Coordinator

Reports to: Policy & Appeals Supervisor

FLSA status: Non-exempt

Position Summary
The Appeals Coordinator is responsible for receiving, investigating, and responding in writing to YHI appeals, Department of Health and Welfare (DHW) eligibility appeals, Department of Insurance (DOI) complaints, as well as Federal Marketplace appeals and hearings. Communication and processing of requests must reflect knowledge and understanding of federal, state, and YHI-specific policy requirements. This position is responsible for ensuring federally mandated timelines are adhered to and each case is appropriately reviewed. This position often has to understand and communicate policy, analyze data about policy and the ACA, synthesize that with a knowledge of YHI and the ACA as it functions in Idaho, and communicate policy requirements across diverse groups.

Company Overview

The Idaho Health Insurance Exchange, dba Your Health Idaho, was established in 2013 by Idaho House Bill 248. We are an independent entity overseen by a 19-member Board of Directors. Your Health Idaho is Idaho’s online marketplace where Idaho individuals, families, and small businesses can shop, compare, and choose the health insurance that’s right for them. We are also the only place where Idahoans can apply for and receive a tax credit that can pay for some or all of their monthly premiums. We serve over 100,000 Idahoans and support ~$500m in annual premiums. Your Health Idaho has received multiple awards for our culture and is recognized as a premier employer in the Treasure Valley.

Responsibilities (Position may include additional functions not listed)

• Makes initial and follow up contacts with consumers/consumer connectors regarding appeal requests. Responds to members, Consumer Connectors, and authorized representatives regarding YHI’s appeal decisions.
• Ensures timeframes are met while supporting a wide range of complex consumer questions.
• Analyzes appeals requests, evaluates unique circumstances, interprets ACA policy requirements and YHI policies/practices, and determines appeal decisions.
• Manages the resolution of eligibility and enrollment appeals and complaint cases including escalated cases. Prepares all appeals cases in accordance with regulations, compliance standards, and policies and procedures.
• Investigates all complaints, grievances and appeals, including collection of appropriate documentation. Attends appeal hearings and participates in departmental meetings, trainings, and internal process improvement efforts requested.
• Works independently with internal and external partners to research, document, resolve and make timely determinations for appeals and grievances.
• Extract, manage and analyze appeal related data, requests, and causes to measure and track trending behaviors.
• The position contributes to the compliance of YHI regarding 45 CFR 155.500, Appeals and Complaints. Must meet federally established service levels and noticing requirements, as well as complete the reviews in a manner that reflects policy knowledge and understanding.
• Research appeals specifics and prepare documentation for appeals hearings, including redaction of final hearing decisions for publication and act as a moderator and scribe for the appeals hearing process.
• Offers process improvement and system enhancement suggestions based on appeal decisions and category tracking, as well as performance or training opportunities based on the same.
• Perform other duties as assigned.

Qualifications (Required knowledge, skills, abilities, education, experience, etc.)

• BA/BS in health policy or a related field or equivalent through professional experience
• More than two years related experience in policy research and analysis, or in a position responsible for consumer grievances or appeals
• Proficient understanding of the Affordable Care Act (ACA)
• Working knowledge of healthcare assistance and/or insurance industry policies and operations
• Ability to read, understand, and effectively interpret complex regulatory materials
• Excellent oral and written communication skills as well as good proofreading ability
• Excellent computer skills, including Microsoft Office; ability to learn/utilize other applications
• Strong reading comprehension, attention to detail, organizational, and problem-solving skills
• Ability to work in a fast-paced workplace, adapt to a continually evolving environment, and work independently with limited supervision
• A committed team player with exceptional interpersonal, problem-solving, and communication skills with ability to develop and maintain cooperative and productive work relationships
• Ability to assume responsibility and maintain confidentiality consistent with the values and integrity of YHI

Physical & Other Requirements

• Ability to work in office setting; primarily sedentary; use of normal office machines
• Ability to listen to and understand others as well as ability to give and receive instructions via telephone, computer messages, face-to-face, and in writing
• Ability to operate computer and software applications
• Availability to work additional hours or weekends as projects demand

*The functions described herein are not the only responsibilities and tasks to be performed by the individual occupying this position. The individual will be required to follow any other instructions and to perform any other job-related duties as required by his/her supervisor or manager. Requirements stated herein are minimum levels of knowledge, skills, and/or abilities to qualify for this position. To perform the responsibilities of this position successfully, the individual will possess the abilities and aptitudes to perform each task proficiently. “Ability” means to possess and apply both knowledge and skill.

This job description includes the essential functions of the job that an incumbent must be able to perform with or without reasonable accommodation.

This document does not create an employment contract, implied or otherwise. The organization maintains “at will” employment. This job description is subject to review and may be revised or updated at management’s discretion.

Requirements: