Fair Hearing - Medical Insurance

Position Summary

Medicaid Appeals, Grievance & Fair Hearing Officer is a senior administrative and compliance role responsible for overseeing Medicaid grievances, appeals, and State Fair Hearing activities in compliance with 42 CFR Part 438. This position serves as the organization’s primary subject matter expert on adverse benefit determinations, authorization denials, continuation of benefits, and Ohio Medicaid State Fair Hearing preparation and representation.

Key Responsibilities & Role Highlights

• Oversee and manage Medicaid grievances and appeals related to service denials, reductions, suspensions, terminations, and failure-to-act cases in accordance with regulatory requirements.
• Ensure Notices of Action are issued and reviewed for compliance, including required timelines, content, appeal rights, and continuation of benefits provisions.
• Cook up with clinical, utilization management, billing, and provider teams to gather documentation and support appeal determinations.
• Lead the preparation and coordination of Ohio Medicaid State Fair Hearings, including appeal summaries, hearing packets, and supporting documentation.
• Represent or support the organization during hearings before the Ohio Department of Job and Family Services (ODJFS) Bureau of State Hearings.
• Provide guidance and training to providers and staff regarding Medicaid appeals, grievances, hearing rights, and regulatory requirements.
• Monitor, identify, and escalate compliance concerns, including potential issues related to denials, recoupments, and adverse benefit determinations.
• Analyze grievance and appeal trends, prepare reports for leadership, and recommend quality improvement and risk mitigation strategies.

Education & Experience Requirements

• Bachelor’s degree in health administration, Social Work, Public Administration, Legal Studies, or a related field required.
• Experience managing Medicaid grievances, appeals, and/or State Fair Hearing processes required.
• Working knowledge of Medicaid regulations, including 42 CFR Part 438.
• Strong written and verbal communication skills, with the ability to prepare formal appeal summaries and case documentation.
• Master’s degree or advanced credential preferred (e.g., JD, RN, LISW-S, LPCC-S, or equivalent).
• Experience representing or supporting cases in Ohio Medicaid State Fair Hearings preferred.
• Knowledge of behavioral health, substance use disorder (SUD), and/or long-term services and supports (LTSS) preferred.
• Strong organizational, analytical, and problem-solving skills with attention to detail and regulatory compliance.

Compensation & Benefits

Paid Time Off (PTO) Starting at 16 Days/Year
Medical with federal minimum deductibles
Dental and Vision coverage
Retirement planning and employer contribution