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Appeals Specialist The candidate will ensure the timely and fair resolution of appeals in a manner consistent with regulatory requirements of the U.S. Department of Health and Human Services, and the Exchange’s policies and procedures. May request an appeals hearing if they disagree with the Exchange’s recent decision regarding their eligibility to enroll in a qualified health plan, receive tax credit, and/or the amount of tax credit. Research, evaluate, prepare, and present cases heard by the Presiding Officer. Represents the firm during these administrative hearings. Make timely decisions in accordance with federal regulations and WAHBE policies. Make decisions to grant or deny customer requests for Special Enrollment Period, Retroactive Termination, Retroactive Enrollment, Re-Instatement, Reactivation, and for correcting any system errors regarding the customer eligibility for tax credits. Provide excellent customer service, consider customer needs, answer questions with accuracy and respect, and resolve issues quickly. Work with difficult and angry customers to resolve disputes by explaining decisions and organization policies. Assist customer with their Washington Healthplanfinder accounts, including but not limited to explaining the meaning of questions, providing information about appropriate tax and legal resources, with customer consent making corrections to account, manually calculating tax credits and explaining how tax credits are calculated, and assisting customer and employers in complying with the requirements of the Act. Investigate customer requests regarding enrollment using a multitude of tools and personal judgement. Investigate employer requests regarding their employee’s enrollment and eligibility for tax credits. Make decisions to grant or deny customer requests based on WAHBE policies and federal regulations. Review documents for customers who are conditionally eligible and determine whether documents provided prove statements the customer has made regarding their citizenship, lawful presence, a qualifying life event. Perform mathematical testing using approved algorithms to determine if the documents provided by the customer prove the customer’s attested income. Grant or deny customer eligibility for subsidies based on the results of this investigation. Effectively separate the duties and responsibilities relating to appeals and appellants from duties and responsibilities to make enrollment decisions. Manage the submission, investigation, and timely resolution of exemption requests, appeals, grievances, and/or complaints submitted through Washington Healthplanfinder. Enter customer’s personal information, as needed, into the Exchange’s case management’s tracking system, and maintain current case activity (including preparing summaries, drafting correspondence and administrative orders, and maintaining statistical records), ensuring the confidentiality, accuracy, and integrity of the customer information. Research issues and ascertain facts using state and federal databases, knowledge of Affordable Care Act eligibility standards, and approved decision tools as established by Exchange’s policies, procedures and regulatory requirements. Ensure each appellant and requestor receives notifications, acknowledgements, and decision in compliance with federal regulations, program standards, and performance expectations. Request, obtain, and conduct assessments of appellant’s personal financial records, state wage data, citizenship and lawful presence documents, tribal membership verification, medical notes and diagnoses, as appropriate to determine the facts of an appeal or request for exemption. Elevate issues to the appropriate manager or leadership as necessary. Coordinate with other agencies as necessary. Other duties as assigned. Must have a Bachelor’s degree in public administration, business administration, or related field. Must have 2 years of progressively responsible experience in Medicaid or public assistance eligibility, grievance resolution, or administrative appeals processes. Experience in health care, public service, health insurance, or public assistance is preferred. Should have strong written and verbal communication skills. Ability to write clear, concise and accurate letters, reports, narratives and orders is required. Should have willingness to communicate with limited English speaking appellants and use a language interpreter when necessary. Ability to accept responsibility for professional development and interpersonal relationship is required. Should have the ability to build and maintain internal and external customer focus. Must have strong interpersonal skills; ability to work with all levels of internal management and staff, as well as diverse populations, stakeholder groups, and customers. Must be proficient in using Microsoft Office Software, including Word, Excel, PowerPoint, Outlook, and/or Access. Should be skilled in reading, understanding, interpreting, and applying complex state and federal regulations. Must have the ability to reduce large and complex volumes of information into concise and easily understandable points. Bi-lingual (Spanish) is a plus. Health Plan background is preferred. Must have knowledge of the administrative hearings process or para-legal background (Legal Secretary, Paralegal, Case File Manager). Experience interpreting and applying enrollment and eligibility federal regulation associated with the Affordable Care Act is required.
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