Appeals Specialist

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Appeals Specialist
The candidate reports to the Eligibility Manager, and will ensure the timely and fair resolution of appeals in a manner consistent with regulatory requirements of the U.S. Department of Health and Human Services, and the Exchange’s policies and procedures. Applicants may request an appeal hearing if they disagree with the Exchange’s recent decision regarding their eligibility to enroll in a qualified health plan, receive tax credit, and/or the amount of tax credit or a denial of a Special Enrollment Period. Employers may appeal an employee’s eligibility to receive a tax credit. Researches, evaluates, prepares, and presents cases heard by a Presiding Officer. Represents firm during these administrative hearings. In addition, are responsible for making timely decisions in accordance with federal regulations and firm policies. Will have authority to make decisions to grant or deny customer requests for a Special Enrollment Period, Retroactive Termination, Retroactive Enrollment, Re-Instatement, Reactivation, and for correcting any system errors regarding the customer’s eligibility. Analyze, research, and apply complex federal eligibility regulations published in the Federal Code of Regulations to resolve complex eligibility issues. Provide excellent customer service, consider customer needs, answer questions with accuracy and respect, and resolve issues quickly. Work with difficult and angry customers to resolve disputes by explaining decisions and organization policies. Assist customers with their Healthplanfinder accounts, including but not limited to explaining the meaning of questions, providing information about appropriate tax and legal resources, make corrections to an account with customer consent, manually calculating tax credits ,explaining how tax credits are calculated, and assisting customers and employers in complying with the requirements of the Affordable Care Act. Investigate customer requests regarding eligibility and enrollment using a multiple interdependent electronic systems and personal judgement. Investigate employer appeals regarding their employees’ Healthplanfinder enrollment and eligibility for tax credits. Manage the submission, investigation, and timely resolution of appeals, grievances, and/or complaints submitted to WAHBE. Make decisions to grant or deny customer requests in accordance with WAHBE policies and federal regulations. Review documents for customers who are conditionally eligible and determine whether the documents provided prove statements the customer made regarding their citizenship, lawful presence, and other unverified information in their application. Perform mathematical testing using approved algorithms to determine if the documents provided by the customer proves the customer’s attested income. Grant or deny customer eligibility for subsidies based on the results of this investigation. Effectively separate the duties and responsibilities relating to appeals and appellants from duties and responsibilities to make enrollment and/or eligibility decisions. Enter customer’s personal information, as needed, into the Exchange’s case management’s tracking system, and maintain current case activity (including, but not limited to preparing summaries, drafting correspondence and administrative orders, and maintaining statistical records), ensuring the confidentiality, accuracy, and integrity of the customer information. Research issues and ascertain facts using state and federal databases, knowledge of Affordable Care Act eligibility standards, and approved decision tools as established by Exchange’s policies, procedures and regulatory requirements. Able to identify Federal Taxpayer Information (FTI) and understand the penalties for the misuse/unauthorized access or disclosure of FTI. Ensure each appellant or requestor receives notifications, acknowledgements, and decisions in compliance with federal regulations, program standards, and performance expectations. Request, obtain, and conduct assessments of appellants’ personal financial records, state wage data, citizenship and lawful presence documents, tribal membership verification, medical notes and diagnoses, as appropriate to determine the facts of an appeal. Prepare all material for appeal case that meets requirements for the appellant and Presiding Officer who will hear the case. Schedule prehearing and/or hearing conferences, notifying Presiding Officers and appellants in accordance with policies and federal regulations. Communicate the Exchange’s position during the appeal and represent the Exchange in a prehearing and/or hearing conference. Communicate highly sensitive and confidential information (electronic, telephonic, and written), both into and out of appeal hearing. Responsible for managing all incoming and outgoing requests, ensuring compliance with timelines and federal and Exchange policies. Elevate issues to the appropriate manager or leadership as necessary. Coordinate with other agencies as necessary. Other duties as assigned.

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