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Title :
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Appeals Coordinator
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Location :
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Western Region
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Classification :
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To be determined by qualification and experience of candidate
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Position # :
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TBA
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General Statement of the Job :
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The Appeals Coordinator is responsible for coordinating the SMC Medicaid and State denial and appeals processes. This includes preparing, proofreading and verifying the accuracy of the SMC notification letters sent to consumers/legal guardians and providers regarding reductions, suspensions, terminations or denials of services; providing support and information to consumers seeking to appeal a service request action; monitoring and maintaining accurate Appeals policies and procedures based on State and Federal regulations; and maintaining/reporting quarterly Medicaid and non-Medicaid appeal statistics. This position also provides paralegal assistance and guidance during Mediation and State Fair Hearing Appeals processes.
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Essential Job Functions :
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Coordination of SMC Medicaid and Non-Medicaid Appeal Processes: When consumers /guardians request a reconsideration review as a result of Reduction, Suspension, Termination or Denial of services, the Coordinator is responsible for ensuring that notification letters are sent to the consumer/guardian and provider, in a timely and accurate manner based on the most current formats and timelines as established by State and Federal regulations. Additionally, the coordinator is responsible for following through with tracking appeal requests and assignment of the local reconsideration review process; continuation of tracking and facilitating SMC involvement in Appeals process through resolution; documentation of all contacts with consumer/guardian, reviewer(s) and providers; and establishes and maintains the Denial and Appeals documentation and log.
Resource/Training – The Appeals Coordinator will serve as a resource in the denial and appeals processes by providing assistance and advice to SMC staff in developing and streamlining policies and procedures to further meet the needs and requirements of SMC Clinical Operations in coordination with State and federal regulations. This position will be responsible for identifying, tracking and initiating training on Denial and Appeals as determined by the internal quality management reviews performed.
Litigation Liaison - The Appeals Coordinator will conduct paralegal duties to aid external SMC contracted legal representatives in preparation for SMC specific Appeals related cases. These duties may include: aiding counsel in ensuring clear communication and exchange of documents are effectively made between all parties involved in appeals process; responsible for file readiness and ensuring that SMC members have appropriate documentation and are prepared for mediation and hearings; attends mediation and hearings; assists in the discovery process; drafts any OAH documents as directed; and any other tasks as directed to support SMC legal team.
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Minimum Training and Qualifications :
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Graduation from an accredited school for paralegal training and one year of experience as a paralegal, or graduation from a four-year college or university with a degree in English, Journalism, or a degree directly related to the area assigned and one year of substantive paralegal experience; or graduation from high school and five years of paralegal experience performing delegated, substantive legal work, or an equivalent combination of training and experience.
Minimum Education and Experience for a Trainee Appointment - Graduation from an accredited school for paralegal training; or graduation from a four-year college or university with a degree in English, Journalism, or a degree directly related to the area assigned; or graduation from high school and four years of paralegal experience performing delegated, substantive legal work. All degrees must be received from appropriately accredited institutions.
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Physical Requirements :
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Normal range of motion and reasonable physical health and strength will be required. Must reach families in homes, which may not be handicapped accessible. Visual attention sufficient to read, operate a motor vehicle and to observe family interactive process is necessary. Must have driver’s license. Mental concentration is required in the planning of complex interventions, review of assessments, etc. Typewriters, computers, copiers and other office equipment will be used routinely.
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Knowledge of Job :
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-Knowledge of Federal and State regulations on Behavioral Healthcare denials and appeals processes.
-Knowledge on medical records practices and records keeping 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 paralegal duties that pertain to SMC policies and procedures
The employee must have strong writing and editing skills. Must be detail oriented and able to organize multiple tasks and priorities, and to effectively manage large projects from start to finish. Work activities quickly change according to mandated changes and changing priorities at the state level. The employee must be able to change the focus of his/her activities to meet changing priorities. Proficiency in Microsoft Office products (such as Word, Excel, Outlook, PowerPoint, etc) is required.
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Salary :
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Grade/Step is determined by qualification and experience of candidate. Salary Range is $27,981 - $33,305. Position is full-time salaried with comprehensive benefits. Work schedule is 37.5 hours per week. This position is exempt from overtime compensation.
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Deadline for Application :
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Position is open until filled
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Apply To :
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Send a NC State Application and resume to: Smoky Mountain Center, Department of Human Resources, 44 Bonnie Lane, Sylva, NC 28779. Smoky Mountain Center is an equal opportunity, affirmative action employer
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PLEASE NOTE THAT INTERNAL APPLICANTS SHOULD BE AWARE THAT CHANGING POSITIONS
WITHIN THE AGENCY COULD RESULT IN BEING RECLASSIFIED INTO TRAINEE STATUS WHICH
WOULD AFFECT YOUR RIGHTS AS A PERMANENT EMPLOYEE. WHEN APPLYING INTERNALLY, CHECK
CLOSELY WITH HIRING SUPERVISOR AND HUMAN RESOURCES COORDINATOR TO DETERMINE IF YOU
ARE FULLY QUALIFIED FOR POSITION OR IF YOU MUST SERVE IN TRAINEE STATUS UNTIL FULLY
QUALIFIED.
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