Medicaid Appeals Coordinator

Job Title: Medicaid Appeals Coordinator

Pay Rate: $26.00/hr. on W2 without benefits

Duration: 10+ months

Work Hours: 8:00 am to 4:00 pm or 9:00 am to 5:00 pm

Job Description: 

• Under the supervision of Regulatory Officer 2, and in support of the Fair Hearing Unit's efforts to process Medicaid Fair Hearing appeals in a timely and accurate manner, the Program Support Specialist performs a variety of administrative, technical, and program support functions necessary to ensure compliance with federal and State Fair Hearing requirements. 
• Additional resources are also needed to develop an informal resolution process and identify cases that can be resolved prior to transmittal to the Office of Administrative
• Ongoing delays may result in corrective action or financial penalties. 
  The CMS Compliance Plan also requires measurable improvements in case processing timeliness, accuracy of case closure and benefit updates, and reliable data reporting, which are areas that depend on both staffing capacity and upgraded technology. 

Case Processing, Transmittals, and Informal Resolution: 

• The CMS Compliance Plan requires timely receipt, triage, and transmittal of all Fair
• Hearing requests. Current staffing levels cannot keep pace with sustained case volume, now further increased by new legislation, work requirements, and rising renewal activity. Additional staffing is needed to process requests in real time, conduct enhanced case triage, and identify cases appropriate for informal resolution before transmittal to the OAL.
• Strengthening these front-end functions directly supports 
• CMS's expectations for timely case movement, reduces unnecessary hearings, and improves the overall experience for beneficiaries. 

Case Closure, Scanning, and Verification: 

• The Compliance Plan emphasizes the need for timely and accurate closure of resolved or withdrawn cases, including confirmation of benefit status. These activities require consistent scanning, document processing, system updates, and coordination with counties, Managed Care Organizations (MCOs), and the Health Benefits Coordinator. Increased staffing is needed to ensure these functions occur reliably, prevent recurring delays, and maintain the accuracy CMS requires for oversight and reporting. 

Data Reconciliation and Reporting: 

• CMS requires accurate, reconciled data across DMAHS, OAL, counties, MCOs, and other partners. Increasing hearing volume and historical inconsistencies require dedicated staff to manage reconciliation, validate records, and maintain required reporting tools. 

Technology Modernization and System Improvements: 

• The CMS Compliance Plan also identifies significant modernization and workflow improvements that must be supported to achieve and sustain compliance. This includes strengthening the Fair Hearing tracking system to support real-time updates and reporting, developing system functionality to support informal resolution and enhanced triage, improving electronic integration and data exchange with the OAL, standardizing and automating member notices and workflow steps to reduce manual processing, and expanding dashboards and analytics tools needed for compliance monitoring.
• Developing and implementing these improvements requires dedicated staffing to support business requirements, system design, testing, data validation, and rollout while maintaining day-to-day operational functions.

Responsibilities: 

• Analyze incoming mail, faxes, correspondence, and appeal requests to determine contested issues. 
  Input 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 the Office of Administrative Law (OAL) for scheduling. 
• Track contested cases throughout the appeals lifecycle, monitor case status, and ensure timely processing, resolution, and closure. 
• Monitor terminations and continuation of benefits by coordinating with the MCO
• Coordinator Unit, including requests to add or remove the appropriate "19 " code based on case status. 
• Coordinate informal resolution efforts by communicating with County Welfare
• Agencies (CWAs), Managed Care Organizations (MCOs), OCCO, providers, petitioners, representatives, and other eligibility-determining agencies regarding settlements, withdrawals, resolutions, and requests for additional information. 
• Return matters to CWAs for re-review when appropriate, including failure-to-provide termination cases. 
• Respond to inquiries regarding program activities and Fair Hearing requirements and refer complex matters to senior staff. 
• Prepare and maintain transmittal documents, legal correspondence, case summaries, charts, reports, tables, and other materials supporting program operations. 
• Generate monthly reports detailing outstanding, accepted, declined, resolved, and pending Fair Hearing requests. 
• Research applicable federal and State laws, regulations, policies, and procedures supporting the Fair Hearing process. 
• Scan, organize, maintain, and retain electronic and hard-copy case files, ensuring all supporting documentation and legal records comply with agency record keeping requirements. 
• Monitor and reconcile pending appeals, identify cases requiring additional documentation or agency action, and conduct follow-up with internal and external stakeholders to ensure records remain accurate and complete. 

Required Qualifications:

• Ability to assemble data and prepare accurate and informative reports containing findings, conclusions, and recommendations. 
• Ability to review, interpret, and evaluate data and other information. 
• Ability to read and interpret laws, regulations, standards, policies, and procedures and apply them appropriately. 
• Ability to research legal materials, including court decisions, precedents, legal opinions, and citations, and 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 in Microsoft Office Suite. 
• Ability to read, write, speak, understand, and communicate effectively in English.

• Analyze incoming mail, faxes, correspondence, and appeal requests to determine contested issues. 
• Input 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 the Office of Administrative Law (OAL) for scheduling. 
• Track contested cases throughout the appeals lifecycle, monitor case status, and ensure timely processing, resolution, and closure. 
• Monitor terminations and continuation of benefits by coordinating with the MCO
• Coordinator Unit, including requests to add or remove the appropriate "19 " code based on case status. 
• Coordinate informal resolution efforts by communicating with County Welfare
• Agencies (CWAs), Managed Care Organizations (MCOs), OCCO, providers, petitioners, representatives, and other eligibility-determining agencies regarding settlements, withdrawals, resolutions, and requests for additional information. 
• Return matters to CWAs for re-review when appropriate, including failure-to-provide termination cases. 
• Respond to inquiries regarding program activities and Fair Hearing requirements and refer complex matters to senior staff. 
• Prepare and maintain transmittal documents, legal correspondence, case summaries, charts, reports, tables, and other materials supporting program operations. 
• Generate monthly reports detailing outstanding, accepted, declined, resolved, and pending Fair Hearing requests. 
• Research applicable federal and State laws, regulations, policies, and procedures supporting the Fair Hearing process. 
• Scan, organize, maintain, and retain electronic and hard-copy case files, ensuring all supporting documentation and legal records comply with agency record keeping requirements. 
• Monitor and reconcile pending appeals, identify cases requiring additional documentation or agency action, and conduct follow-up with internal and external stakeholders to ensure records remain accurate and complete.