Medicaid Appeals Coordinator
2 days ago
Trenton
Job Description Duration: 10+ months Job Description • Works under the supervision of Regulatory Officer 2., • Supports the Fair Hearing Unit (FHU) in processing Medicaid Fair Hearing appeals accurately and within required federal and State timelines., • Performs administrative, technical, and program support functions to ensure compliance with federal and New Jersey Fair Hearing requirements. Justification for Additional Staffing • DMAHS is requesting temporary staffing enhancements for the Fair Hearing Unit., • Additional staffing is needed to:, • Meet federal Fair Hearing requirements., • Fulfill obligations under the CMS Fair Hearing Compliance Plan., • Address ongoing workload and accumulated cases., • Support technology modernization., • Meet federally mandated processing timelines., • Develop an informal resolution process., • Identify cases that can be resolved before transmittal to the Office of Administrative Law (OAL)., • Anticipated increases in Fair Hearing volume may result from:, • H.R. 1 changes in citizen eligibility., • Expanded work requirements., • Increased renewal volume. Federal Compliance Drivers • CMS identified New Jersey's Fair Hearing delays as a major compliance concern in its November 26, 2024 letter., • CMS directed the State to restore timely processing before the expiration of federal flexibilities on June 30, 2026., • Key federal requirements include:, • Final administrative action on Fair Hearing requests within 90 days under 42 CFR § 431.244., • Effective oversight by the single State Medicaid agency under 42 CFR § 431.10., • Continued improvement in Fair Hearing processing to avoid corrective action or potential financial consequences., • The CMS Compliance Plan requires improvements in:, • Case-processing timeliness., • Accuracy of case closures., • Benefit updates., • Data reporting., • Staffing capacity., • Technology and workflow systems. Operational Need Case Processing, Transmittals, and Informal Resolution • Process Fair Hearing requests in real time., • Conduct enhanced case triage., • Identify cases appropriate for informal resolution before OAL transmittal., • Support timely case movement and reduce unnecessary hearings., • Improve the overall experience for beneficiaries. Case Closure, Scanning, and Verification • Process resolved and withdrawn cases promptly and accurately., • Confirm benefit status., • Scan and process documents., • Update systems accurately., • Coordinate with counties, Managed Care Organizations (MCOs), and the Health Benefits Coordinator., • Prevent recurring processing delays. Data Reconciliation and Reporting • Reconcile data across DMAHS, OAL, counties, MCOs, and other partners., • Validate records and resolve historical data inconsistencies., • Maintain required reporting tools., • Support accurate compliance reporting. Technology Modernization and System Improvements • Support modernization of the Fair Hearing tracking system., • Enable real-time case updates and reporting., • Develop functionality supporting informal resolution and enhanced triage., • Improve electronic integration and data exchange with OAL., • Standardize and automate member notices and workflow processes., • Expand dashboards and analytics for compliance monitoring., • Support business requirements, system design, testing, data validation, and implementation., • Maintain day-to-day operational functions during system improvements. Primary Duties • Analyze incoming mail, faxes, correspondence, and appeal requests to determine contested issues., • Enter and maintain case information in the LRL Oracle database and other agency information systems., • Review, process, and manage Fair Hearing cases from receipt through final disposition., • Prepare, organize, and transmit Fair Hearing case files to OAL for scheduling., • Track cases throughout the appeals lifecycle., • Monitor case status and ensure timely processing, resolution, and closure., • Monitor terminations and continuation of benefits., • Coordinate with the MCO Coordinator Unit regarding appropriate "19" code updates based on case status., • Coordinate informal resolution efforts with:, • County Welfare Agencies (CWAs)., • Managed Care Organizations (MCOs)., • OCCO., • Providers., • Petitioners and representatives., • Eligibility-determining agencies., • Communicate regarding settlements, withdrawals, resolutions, and requests for additional information., • Return matters to CWAs for re-review when appropriate., • Handle failure-to-provide termination cases., • Respond to inquiries regarding program activities and Fair Hearing requirements., • Refer complex matters to senior staff., • Prepare and maintain:, • Transmittal documents., • Legal correspondence., • Case summaries., • Charts., • Reports., • Tables., • Other program-support materials., • Generate monthly reports covering:, • Outstanding requests., • Accepted requests., • Declined requests., • Resolved requests., • Pending requests., • Research applicable federal and New Jersey laws, regulations, policies, and procedures., • Scan, organize, maintain, and retain electronic and hard-copy case files., • Ensure supporting documentation and legal records comply with agency recordkeeping requirements., • Monitor and reconcile pending appeals., • Identify cases requiring additional documentation or agency action., • Conduct follow-up with internal and external stakeholders to maintain accurate and complete records. Minimum Requirements • Ability to assemble data and prepare accurate, informative reports containing findings, conclusions, and recommendations., • Ability to review, interpret, and evaluate data and other information., • Ability to read, interpret, and appropriately apply:, • Laws., • Regulations., • Standards., • Policies., • Procedures., • Ability to research legal materials, including:, • Court decisions., • Legal precedents., • Legal opinions., • Legal citations., • Ability to evaluate documents for compliance with New Jersey State and federal laws and regulations., • Ability to recognize, analyze, and resolve routine program issues., • Ability to maintain accurate records and files., • Ability to work cooperatively with supervisors, coworkers, and external stakeholders., • Strong analytical and problem-solving skills., • Proficiency with Microsoft Office Suite., • Ability to read, write, speak, understand, and communicate effectively in English. \nCompany Description 22nd Century Technologies, Inc. (TSCTI) is one of the fastest-growing IT Services Integrators and Workforce Solutions providers in the United States. Founded in 1997, TSCTI is a Certified National Minority Business Enterprise (MBE) with a workforce of 6,000+ professionals, including 600+ Cybersecurity Subject Matter Experts (SMEs), delivering mission-critical solutions across all 50 U.S. states, Canada, and Mexico. Headquartered in Princeton, NJ, and McLean, VA, with 14 regional offices nationwide, TSCTI provides comprehensive solutions in Digital Transformation, Artificial Intelligence (AI), Cybersecurity, Cloud Computing, IT Infrastructure, Enterprise Modernization, DevSecOps, Managed Services, Workforce Solutions, and Healthcare Staffing. We are a trusted partner to Federal, State, Local, Education (SLED), Healthcare, and Commercial organizations, delivering innovative technology and talent solutions that enable our clients to achieve their strategic objectives. As one of the nation's leading Healthcare Workforce Solutions providers, TSCTI supports federal healthcare systems, Veterans Affairs (VA) Medical Centers, state and local healthcare agencies, hospitals, clinics, laboratories, long-term care facilities, and commercial healthcare organizations. We recruit and place highly qualified healthcare professionals across a wide range of specialties, including physicians, advanced practice providers, registered nurses, allied health professionals, behavioral health specialists, laboratory personnel, pharmacy professionals, and healthcare administrative staff. Our healthcare solutions ensure continuity of care while maintaining the highest standards of clinical excellence and regulatory compliance. With a strong commitment to quality and compliance, TSCTI operates through CMMI Level 3 (Development & Services) and ISO 9001, ISO 20000, and ISO 27001 certified processes, ensuring consistent service excellence, operational maturity, and information security. Today, we proudly support 14 of the 15 Federal Executive Departments, 37 Federal agencies, 50 State governments, 115+ Local agencies, 37 School Districts, numerous healthcare organizations, and 80+ Fortune 500 and commercial clients. TSCTI has earned numerous industry recognitions, including being named among Forbes America's Best Large Employers, Forbes Best Employers for Veterans, Forbes Best Employers for Tech Workers, Newsweek's America's Greatest Workplaces for Diversity, and a 13-time Inc. 5000 honoree. The company has also been recognized by the Washington Business Journal as one of the Best Places to Work and continues to expand its capabilities through strategic innovation, acquisitions, and investments in emerging technologies. At TSCTI, our people are our greatest strength. We are committed to fostering an inclusive, collaborative, and growth-oriented workplace where innovation thrives and careers flourish. Whether delivering cutting-edge technology solutions or connecting exceptional talent with meaningful careers, we consistently exceed our clients' expectations while empowering our employees to succeed. Equal Opportunity Employer 22nd Century Technologies, Inc. is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, protected veteran status, or any other characteristic protected by applicable federal, state, or local law. 22nd Century Technologies, Inc. (TSCTI) is one of the fastest-growing IT Services Integrators and Workforce Solutions providers in the United States. Founded in 1997, TSCTI is a Certified National Minority Business Enterprise (MBE) with a workforce of 6,000+ professionals, including 600+ Cybersecurity Subject Matter Experts (SMEs), delivering mission-critical solutions across all 50 U.S. states, Canada, and Mexico.\r\n\r\nHeadquartered in Princeton, NJ, and McLean, VA, with 14 regional offices nationwide, TSCTI provides comprehensive solutions in Digital Transformation, Artificial Intelligence (AI), Cybersecurity, Cloud Computing, IT Infrastructure, Enterprise Modernization, DevSecOps, Managed Services, Workforce Solutions, and Healthcare Staffing. We are a trusted partner to Federal, State, Local, Education (SLED), Healthcare, and Commercial organizations, delivering innovative technology and talent solutions that enable our clients to achieve their strategic objectives.\r\n\r\nAs one of the nation's leading Healthcare Workforce Solutions providers, TSCTI supports federal healthcare systems, Veterans Affairs (VA) Medical Centers, state and local healthcare agencies, hospitals, clinics, laboratories, long-term care facilities, and commercial healthcare organizations. We recruit and place highly qualified healthcare professionals across a wide range of specialties, including physicians, advanced practice providers, registered nurses, allied health professionals, behavioral health specialists, laboratory personnel, pharmacy professionals, and healthcare administrative staff. Our healthcare solutions ensure continuity of care while maintaining the highest standards of clinical excellence and regulatory compliance.\r\n\r\nWith a strong commitment to quality and compliance, TSCTI operates through CMMI Level 3 (Development & Services) and ISO 9001, ISO 20000, and ISO 27001 certified processes, ensuring consistent service excellence, operational maturity, and information security. Today, we proudly support 14 of the 15 Federal Executive Departments, 37 Federal agencies, 50 State governments, 115+ Local agencies, 37 School Districts, numerous healthcare organizations, and 80+ Fortune 500 and commercial clients.\r\n\r\nTSCTI has earned numerous industry recognitions, including being named among Forbes America's Best Large Employers, Forbes Best Employers for Veterans, Forbes Best Employers for Tech Workers, Newsweek's America's Greatest Workplaces for Diversity, and a 13-time Inc. 5000 honoree. The company has also been recognized by the Washington Business Journal as one of the Best Places to Work and continues to expand its capabilities through strategic innovation, acquisitions, and investments in emerging technologies.\r\n\r\nAt TSCTI, our people are our greatest strength. We are committed to fostering an inclusive, collaborative, and growth-oriented workplace where innovation thrives and careers flourish. Whether delivering cutting-edge technology solutions or connecting exceptional talent with meaningful careers, we consistently exceed our clients' expectations while empowering our employees to succeed.\r\n\r\nEqual Opportunity Employer\r\n\r\n22nd Century Technologies, Inc. is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, protected veteran status, or any other characteristic protected by applicable federal, state, or local law.