Appeals Manager

This position is exempt from the State Human Resources Act

TELEWORK AVAILABILITY: We trust our employees to be self-motivated and successful in hybrid/remote roles; NC Department of Health and Human Services offers work from home options and variable work schedule flexibility for this position.

Division of Health Benefits employees with an approved hybrid telework schedule are currently expected to work onsite at their assigned duty station at least 4 working days per month or more as needed for business operations.  Telework options are subject to change at the discretion of management. More information on this arrangement may be obtained at the time of interview.

This position's duty station is assigned to Dix Campus in Raleigh, North Carolina.

Position Summary

The Division of Health Benefits Legal Office supports 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 Hearings and Appeals Unit provides 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 Department of Justice (DOJ), Attorney General's Office and other external stakeholders.

The Appeals Manager, reporting to the Associate Director of Appeals, is 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.

To receive credit for all of your work history and credentials, you must list the information on the application form. Any information listed under the text resume section or on an attachment will not be considered for qualifying credit. Qualified applicants must document on the application that they possess all of the following:

• Experience communicating effectively with internal and external stakeholders.

• Knowledge and understanding of the healthcare industry and associated hearings, appeals and due process regulatory requirements.

• Knowledge of Medicaid programs and current initiatives.

• Experience preparing and interpreting financial and operational reports.

• Experience exercising judgement and discretion in establishing, applying, interpreting, and evaluating policies and procedures.

• Demonstrated proficiency in Microsoft Office products such as Excel, Outlook, and Word.

Management Preferences:

• Previous and proven work experience at Division of Health Benefits/NC Medicaid.

• Familiarity with relevant and current NC Medicaid operations.

• Previous experience in legal field.

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 oshr.nc.gov/experience-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.

Degrees must be from appropriately accredited colleges or universities.

The North Carolina Department of Health and Human Services is an Equal Opportunity Employer.

Pre-employment criminal background checks are required for all positions with the Division of Health Benefits (DHB).

About NC Medicaid (Division of Health Benefits)

The North Carolina Department of Health and Human Services (NCDHHS) works closely with beneficiaries, health care professionals, community leaders and advocacy groups; local, state and federal entities; and other community partners vested to improve the health and safety of all North Carolinians by providing essential human services. NCDHHS is one of the largest, most complex agencies in the state, with about 17,000 employees.

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, NC Medicaid Managed Care 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 $21 billion in state and federal funds per fiscal year, DHB ensures that more than 96,000 enrolled providers are reimbursed for delivering covered services to 2.9 million beneficiaries.

Realizing the strength of DHB lies in its employees, DHB remains dedicated in its efforts to create and maintain a diverse, equitable and inclusive workplace environment.

Application Process

Applicants are encouraged to apply for positions of interest, regardless of their current grade level and job classification. A pay increase may or may not result. Salary decisions are based on relevant education and experience, budget, and internal equity.

To be under consideration for this vacancy, all applicants must complete an online application using this link: https://www.governmentjobs.com/careers/northcarolina. If multiple applications are submitted to an individual posting, only the most recent application received prior to the posting close date will be evaluated for consideration.

Due to the volume of applications received, we are unable to provide information regarding the status of your application. To check the status of your application, please log in to your GovernmentJobs.com account. You will either receive a call or email to schedule an interview or an email notifying you when the job has been filled. For technical issues with your application, please call the NeoGov Help Line at 855-524-5627.  If there are any questions about this posting other than your application status, please contact us at Medicaid.Recruitment@dhhs.nc.gov.