Appeals Manager at North Carolina Dept of Environmental Quality

, North Carolina, United States -

Full Time

Start Date

Immediate

Expiry Date

04 Jul, 26

Salary

111871.0

Posted On

05 Apr, 26

Experience

5 year(s) or above

Remote Job

Yes

Telecommute

Yes

Sponsor Visa

Skills

Medicaid, Appeals management, Grievance resolution, Regulatory compliance, Personnel management, Policy analysis, Stakeholder coordination, Healthcare administration, Due process, Microsoft Office, Leadership, Legal compliance, Program management, Conflict resolution, Communication skills

Industry

Government Administration

Description

Agency Dept of Health and Human Services Division HEALTH BENEFITS Job Classification Title Human Services Program Manager I (NS) Position Number 60090712 Grade NC18 About Us The North Carolina Department of Health and Human Services (DHHS) is one of the largest, most complex agencies in the state, and has approximately 17,000 employees. It is responsible for ensuring the health, safety, and well-being of all North Carolinians, providing human service needs for special populations including individuals who are deaf, blind, developmentally disabled, and mentally ill, and helping poor North Carolinians achieve economic independence. Description of Work The purpose of the Division of Health Benefits Legal Office is to support the legal and compliance functions for Medicaid within the State of North Carolina. In addition, the Legal Office provides executive oversight and leadership for the Hearings and Appeals Unit. The purpose of the Hearings and Appeals Unit is to provide coordination of fee for service appeals and grievances by providers, beneficiaries and claimants and provide oversight and monitoring of appeals and grievances under managed care. The unit also manages due process compliance which includes training, tactical oversight, and stakeholder coordination. The unit coordinates with the DOJ, Attorney General’s Office and other external stakeholders. The purpose of this position is to work as an integral member of the Medicaid Appeals team that provides oversight of appeal and grievance functions, processes, and initiatives, troubling shooting issues, and other tasks and items that arise for Medicaid Beneficiary Appeals and grievances and Provider Claim appeals. Job Specific Responsibilities: • Research, analyze, and interpret varying laws, regulations, and policies to ensure full compliance with all due process requirements. • Engage in personnel administration to include but not limited to recruiting, coaching, selecting, and managing employees, including disciplinary and termination actions as needed; delegating to staff members; encouraging and fostering professional development; establishing effective professional goals and work plan objectives. • Assist with monitoring provider and vendor compliance with laws and regulations regarding Medicaid appeals to ensure compliance with appeal rights afforded to all NC Medicaid beneficiaries and providers. • Update and revise or create NC Medicaid appeal templates as needed for Medicaid vendors and internal DHB units. • Assist in responding to Medicaid appeal and grievance questions from vendors, DHB, staff, NC representatives on behalf of their constituents. • Assist in reviewing and commenting on Medicaid appeal and grievance deliverables submitted by PHP (Prepaid Health Plans) or other entities. • Facilitate the resolution of member grievances that are escalated to the Department. • Serve as the business owner for the contract with the Office of Administrative Hearings as it relates to State Fair Hearing delegation. • Serve as the business owner for the Appeals Clearinghouse. Knowledge Skills and Abilities/Management Preferences Salary Grade Range $63,927 - $111,871 Recruitment Range $63,927 - $82,159 **Position is eligible for a hybrid-teleworking schedule to include weekly onsite work hours** Candidates now meet the minimum qualifications of a position if they meet the minimum education and experience listed on the vacancy announcement. The Knowledge, Skills, and Abilities (KSAs)/ Management Preferences are not required. Applicants who possess the following skills are preferred: Proven ability in establishing and maintaining effective working relationships with internal and external stakeholders through verbal and written communication skills. Knowledge and understanding of the healthcare industry and associated hearings, appeals and due process regulatory requirements. Knowledge of Medicaid programs, current health initiatives, and the understanding of program management including operational design and implementation. Ability to exercise judgement and discretion in establishing, applying, interpreting, and evaluating policies and procedures. Demonstrated proficiency in Microsoft Office products such as Excel, Outlook, and Word. Posting closes at 11:59 p.m. the night before the closing date Position is funded in part through federal funds About the NC Division of Health Benefits: The Division of Health Benefits (DHB) within NCDHHS is committed to advancing innovative solutions that improve health, promote well-being and foster independence for all North Carolinians. DHB manages and oversees North Carolina Medicaid and other programs that provide access to services and supports for parents, children, seniors, people with intellectual / developmental disabilities, and behavioral health, substance use and traumatic brain injury disorders. With a budget over $27 billion in state and federal funds per fiscal year, DHB ensures that more than 108,000 enrolled providers are reimbursed for delivering covered services to 3.1 million beneficiaries. Compensation & Benefits: The State of North Carolina offers excellent comprehensive benefits. Employees can participate in health insurance options, standard and supplemental retirement plans, and the NCFlex program (numerous high-quality, low-cost benefits on a pre-tax basis). Employees also receive paid vacation, sick, and community service leave. In addition, paid parental leave is available to eligible employees. Visit website for State Benefits Supplemental and Contact Information The North Carolina Department of Health and Human Services (DHHS) is an Equal Opportunity Employer that embraces an Employment First philosophy, which consists of complying with all federal laws, state laws, and Executive Orders. We are committed to reviewing requests for reasonable accommodation at any time during the hiring process or while on the job. For more information about DHHS: https://www.ncdhhs.gov/. DHHS uses the Merit-Based Recruitment and Selection Plan to fill positions subject to the State Human Resources Act with the most qualified individuals. Hiring salary will be based on relevant qualifications, internal equity, and budgetary considerations pertinent to the advertised position. In accordance with the Governor’s Executive Order 303, our agency supports second-chance employment for individuals who were previously incarcerated or justice-involved. We invite all potential applicants to apply for positions for which they may be qualified. Application Process Be sure to complete the application in its entirety. Resumes will not be accepted in lieu of completing this application. Information should be provided in the appropriate areas, to include the following: Education, including high school and all degrees obtained, Work Experience, and Certificates & Licenses. It is critical to our screening and salary determination process that applications contain comprehensive candidate information. Answers to Supplemental Questions are not a substitute for providing all relevant information within the body of your application. To receive credit for the supplemental questions, you must provide supporting information within the "Work Experience" section of the application to support your answers. If multiple applications are submitted to an individual posting, only the most recent application received prior to the closing date will be accepted. Applications must be submitted by 11:59 PM the night BEFORE the closing date. Applicants may be subject to a criminal background check. All candidates selected for positions considered "Positions of Trust" will be subject to a criminal background check. Due to the volume of applications received, we are unable to provide information regarding the status of your application over the phone. To check the status of your application, please log in to your account. Upon the closing date, applications are "Under Review" and will be screened by Human Resources for qualified applicants. The hiring process may take several weeks. Degrees must be received from appropriately accredited institutions. Transcripts and degree evaluations may be uploaded with your application. The State of North Carolina/Office of State Human Resources uses the National Association of Credential Evaluation Services (NACES) as a referral resource for applicants who need to have their credentials certified as equivalent. For a list of organizations that perform this specialized service, please visit the NACES membership website at https://www.naces.org/members. Degree/College Credit Verification Degrees must be received from appropriately accredited institutions. Transcripts, degree evaluations and cover letters may be uploaded with your application. Veterans’ and National Guard Preference Applicants seeking Veteran's Preference must attach a DD-214 Member-4 Form (Certificate of Release or Discharge from Active Duty) to their applications. Applicants seeking National Guard Preference must attach an NGB 23A (RPAS), along with the state application, if they are a current member of the NC National Guard in good standing. Applicants who are former members of either the NC Army National Guard or the NC Air National Guard, with honorable discharge and six years of creditable service, must attach a copy of the DD 256 or NGB 22, along with the state application. ADA Accommodations Consistent with the Americans with Disabilities Act (ADA) and the Pregnant Workers Fairness Act (PWFA), DHHS is committed to the full inclusion of all qualified individuals. As part of this commitment, DHHS will ensure that people with disabilities, or known limitations covered by the PWFA, are provided with reasonable accommodation. If reasonable accommodation is needed to participate in the job application or interview process, please contact the person Substance Abuse Professional Practice Board, etc.) indicated below. CONTACT INFORMATION: If there are any questions about this posting, please contact Talent Acquisition at talentacquisition@dhhs.nc.gov. Resumes will not be accepted in lieu of completing this application. Minimum Education and Experience Some state job postings say you can qualify by an “equivalent combination of education and experience.” If that language appears below, then you may qualify through EITHER years of education OR years of directly related experience, OR a combination of both. See the Education and Experience Equivalency Guide for details. Some state job postings say you can qualify by an “equivalent combination of education and experience.” If that language appears below, then you may qualify through EITHER years of education OR years of directly related experience, OR a combination of both. See the Education and Experience Equivalency Guide for details. Master's degree in the area of assignment from an appropriately accredited institution and three years of experience in a closely related program; or Bachelor's degree in the area of assignment field from an appropriately accredited institution and five years of experience in a closely related program; or an equivalent combination of education and experience. EEO Statement The State of North Carolina is an Equal Employment Opportunity Employer and dedicated to providing employees with a work environment free from all forms of unlawful employment discrimination, harassment, or retaliation. The state provides reasonable accommodation to employees and applicants with disabilities; known limitations related to pregnancy, childbirth, or related medical conditions; and for religious beliefs, observances, and practices. Recruiter: Tandrea Lanae Jones Email: talentacquisition@dhhs.nc.gov North Carolina State Government is one of the state’s largest employers, with over 76,000 employees all working toward a common goal: a safer and stronger North Carolina. We are a large organization comprised of various agencies, offices, and universities, each providing important public services. Eligible state employees are entitled to comprehensive benefits, including a variety of leave options, professional development opportunities, insurance, and more. To learn more about the benefits of being a North Carolina state employee, visit the N.C. Office of State Human Resources' website. Permanent, temporary, and time-limited state government jobs can be found from the mountains to the coast. Find your next opportunity today! State Application Resources/Frequently Asked Questions Valuing Education and Experience The State of North Carolina values the knowledge and experience of our jobseekers and current state employees. Approximately 91 percent of state job classifications allow experience to be substituted for education or do not require a post-secondary degree. Learn more about how you may qualify for a position through education or directly related experience, or a combination of both, with the Education and Experience Equivalency Guide. All job postings close at 11:59pm the night before the End Date on the posting. Introduce yourself to our recruiters and we'll get in touch if there's a role that seems like a good match. If you are already a state employee, please search for jobs by clicking here.

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Responsibilities

The Appeals Manager provides oversight for Medicaid beneficiary and provider appeals, ensuring compliance with legal and regulatory requirements. This role also manages personnel, facilitates grievance resolutions, and coordinates with external stakeholders including the Attorney General’s Office.