Administrator ; Appeals & Grievance Administrator

Main Purpose of Job

The main purpose of this position is to provide support to the Appeals and Grievances Manager by researching grievance and appeals histories, organizing information for review, preparing summaries for hearings, and presenting to A&G leadership to ensure timely decision making, accurate reporting and appropriate outcomes.

The position reviews Medicaid eligibility, individual market eligibility appeals, mandate exemption appeals, employer eligibility appeals from the individual market, and appeals of enrollment periods, including special enrollment periods.

This position acts as a policy specialist for Medicaid and the Affordable Care Act and assists with trainings for other departments within Maryland State agencies.

This position will correct IRS Tax Subsidy summaries and will testify and an expert witness during the administrative hearing process.

• 10% – Conduct research and adjudicate a caseload of appeals of individuals, business and/or providers. Interview applicants and representatives associated with investigation.
• 10% – Analyze pertinent facts against appropriate regulatory and policy provisions and develop written recommendations to management for the appeal decision.
• 10% – Develop the supporting case file, in consultation with legal staff, for appeals that elevate to a review by an Administrative Law Judge from the Office of Administrative Hearings. Provide support for adjudication of appeals and hearings as required.
• 10% – Prepare written reports analyzing alternatives and consequences, specifying findings and recommendations for management action, strategy, policy determinations and process changes.
• 10% – Provide extensive interpretation of state and federal eligibility statutes, regulations, policies and guidelines to the administrative vendor, enrolled subscribers and the general public.
• 10% – Conduct review of eligibility appeal requests and supporting documentation, coordinate data collection with appellants perform general case management for appeals.
• 10% – Prepare and present routine appeals cases at OAH.
• 5% – Assist OAG, as needed, in the preparation of complex cases for presentation at OAH.
• 10% – Perform case reviews, appeals and special projects for Maryland Health Benefit Exchange.
• 5% – Acts as a liaison between local agencies.
• 10% – Track and update the MHBE Escalated Cases Tracker for Appeals and Constituent Services. Update and monitor Salesforce for Carrier response and file requests.

• Education:
  
  Graduation from an accredited high school or possession of a high school equivalency certificate.
• Experience:
  
  Four years of administrative staff or professional work.
• Notes:
  • 1. Candidates may substitute 30 college credit hours from an accredited college or university for each year up to four years of the required experience.
  • 2. Candidates may substitute the possession of a Bachelor's degree from an accredited college or university for the required experience.
  • 3. Candidates may substitute the possession of a Master's degree from an accredited college or university for the required experience.
  • 4. Candidates may substitute U.S. Armed Forces military service experience as a commissioned officer involving staff work related to the administration of rules, regulations, policy, procedures and processes, or overseeing or coordinating unit operations or functioning as a staff assistant to a higher ranking commissioned officer on a year-for-year basis for the required experience.

• Two years of experience preparing written case summaries, investigative findings, or recommendations for administrative review, legal proceedings, or management decision-making.
• Two years experience preparing appeal case files or supporting documentation for administrative hearings, including coordination with legal counsel, hearing officers, or administrative law judges.
• Two years experience interpreting and applying Affordable Care Act (ACA), Medicaid, Qualified Health Plan (QHP), Special Enrollment Period (SEP), or Small Business Health Options Program (SHOP) eligibility regulations.

Preference will be given to applicants who possess these…