Title: Appeals Specialist Lead

• 530043

• PHOENIX

• AHCCCS

• Full-time

This position will work independently and will conduct legal research of appeals and claim disputes filed with AHCCCS, and issue Notice of Appeal Resolutions and Notice of Decisions in accordance with federal regulations, state laws, rules, policies, State Plan, contracts and agreements. This position will act as a lead for junior Appeal Specialist positions.

This is a hybrid position with the expectation of being in the office 3 days per week.
The position may offer the ability to work remotely, within Arizona, based upon the department's business needs and continual meeting of expected performance measures.

The State of Arizona strives for a work culture that affords employees flexibility, autonomy, and trust. Across our many agencies, boards, and commissions, many State employees participate in the States Remote Work Program and are able to work remotely in their homes, in offices, and in hoteling spaces. All work, including remote work, should be performed within Arizona unless an exception is properly authorized in advance.

Major duties and responsibilities include, but are not limited to:
* Research appeals and claim disputes to determine jurisdiction, issues, and program liability. Perform legal and programmatic research by obtaining information, analyzing, interpreting and applying federal laws and regulations, state laws and contracts, administrative rules, policies, State Plan, and intergovernmental agreements in order to arrive at sound legal determinations. Act as a resource for Informal Resolution Unit Appeals Specialists by providing guidance and direction.
* Prepare and issue legally sound and accurate Notice of Appeal resolutions and Notice of decisions to notify parties of findings. Represent AHCCCS at State Fair Hearings. Collaborate with the Deputy General Counsel, and Chief Deputy General Counsel as deemed appropriate, and resolve administrative hearing settlements and issues. Act as lead in the production of resolved claim and appeal disputes. Assist and participate in the development and drafting of rules related to the claim dispute and resolution process. Create and maintain dispute resolution templates for the Grievance Unit. In conjunction with the Program Manager, resolve more complex Notices of Appeal Resolution and Notices of Decision and communicate with external parties/stakeholders to address complex cases.
* Serve as subject matter expert related to the technical aspects of the PMMIS Claims Subsystem and as a liaison between OGC Informal Resolution Unit and DFSM Claims Unit regarding the process and payment of provider claims. Serve as one of the database (ProLaw) security administrators for the division.
* Act in a lead capacity, and at times, acting Program Manager for (1) junior Appeals Specialist positions; (2) the Informal Resolution Unit facilitating the resolution of appeals; (3) the production of resolved claim and appeal disputes and (4) assistance to Administrative Services Unit staff on fee for service hearing requests.
* In the absence of the Program Manager, attend meetings and perform other duties including the review, evaluation, issue identification, and assignment of incoming appeals and claim disputes, and attending state fair hearings. Collaborate with the assigned Deputy General Counsel to resolve administrative hearing Settlements and issues.

Extensive Knowledge of:
* Federal and state laws, regulations, Medicaid contracts, intergovernmental agreements, state plan, policies and procedures
* AHCCCS contractor and Health Plan operations
* Department of Economic Security, Department of Health Services, Social Security Administration, and Medicare entitlement programs
* Arizona Office of Administrative Hearings statutes, rules and policies
* Structure and content of the English language including the meaning and spelling of words, rules of composition, and grammar
* Legal and medical terminology
* Knowledge of or ability to learn AHCCCS information systems and databases (i.e., PMMIS, Fortis, XPM, ProLaw, ServiceNow) Long-Term Care, imaging, Internet, Microsoft Outlook, and Google

Advanced Skill in:
* Research, analysis, and negotiation skills
* Legal research, writing methods, and policy analysis
* Organizational and time management
* Oral and written communications
* Interpersonal skills in dealing with all levels of personnel, internal and external
* Interviewing

Ability to:
* Analyze, document, interpret statistics and and comprehend issues legal, factual, statistical information, and programmatic document statistics and issues
* Draw logical conclusions, make judgments and decisions
* Take action or commit to course of action
* Manage a large volume of cases involving a wide variety of legal programmatic, financial and medical issues
* Accurately complete work assignments timely
* Recall information such as words, numbers and procedures
* Plan, organize and prioritize; communicate information and ideas by speaking and writing effectively
* Work independently and under general supervision
* Complete mathematical calculations
* Arrange ideas or actions in a certain order or pattern according to a specific rule or set of rules (i.e., rules/policy)

Minimum:
* Two(2) years experience in Medicaid/Medicare/Commercial insurance claims and/or appeals & claim disputes.
* Or, Bachelor's Degree in healthcare or related fields.

* Successfully complete the Electronic Employment Eligibility Verification Program (E-Verify), applicable to all newly hired State employees.
* Successfully pass fingerprint background check, prior employment verifications and reference checks; employment is contingent upon completion of the above-mentioned process and the agencys ability to reasonably accommodate any restrictions.
* Travel may be required for State business. Employees who drive on state business must complete any required driver training (see Arizona Administrative Code R2-10-207.12.) AND have an acceptable driving record for the last 39 months including no DUI, suspension or revocations and less than 8 points on your license. If an Out of State Driver License was held within the last 39 months, a copy of your MVR (Motor Vehicle Record) is required prior to driving for State Business. Employees may be required to use their own transportation as well as maintaining valid motor vehicle insurance and current Arizona vehicle registration; however, mileage will be reimbursed.

If this position requires driving or the use of a vehicle as an essential function of the job to conduct State business, then the following requirements apply: Drivers License Requirements.

All newly hired State employees are subject to and must successfully complete the Electronic Employment Eligibility Verification Program (E-Verify).

Among the many benefits of a career with the State of Arizona, there are:
* 10 paid holidays per year
* Paid Vacation and Sick time off (13 and 12 days per year respectively) - start earning it your 1st day (prorated for part-time employees)
* Paid Parental Leave-Up to 12 weeks per year paid leave for newborn or newly-placed foster/adopted child (pilot program).
* Other Leaves - Bereavement, civic duty, and military.
* A top-ranked retirement program with lifetime pension benefits
* A robust and affordable insurance plan, including medical, dental, life, and disability insurance
* Participation eligibility in the Public Service Loan Forgiveness Program (must meet qualifications)
* RideShare and Public Transit Subsidy
* A variety of learning and career development opportunities

By providing the option of a full-time or part-time remote work schedule, employees enjoy improved work/life balance, report higher job satisfaction, and are more productive. Remote work is a management option and not an employee entitlement or right. An agency may terminate a remote work agreement at its discretion.

Learn more about the Paid Parental Leave pilot program here. For a complete list of benefits provided by The State of Arizona, please visit our benefits page

Lifetime Pension Benefit Program
* Administered through the Arizona State Retirement System (ASRS)
* Defined benefit plan that provides for life-long income upon retirement.
* Required participation for Long-Term Disability (LTD) and ASRS Retirement plan.
* Pre-taxed payroll contributions begin after a 27-week waiting period (prior contributions may waive the waiting period).

Deferred Retirement Compensation Program
* Voluntary participation.
* Program administered through Nationwide.
* Tax-deferred retirement investments through payroll deductions.

Persons with a disability may request a reasonable accommodation such as a sign language interpreter or an alternative format by emailing careers@azahcccs.gov.
Requests should be made as early as possible to allow time to arrange the accommodation. The State of Arizona is an Equal Opportunity/Reasonable Accommodation Employer.