Marketplace Appeals & Compliance Analyst

Position Overview

The Marketplace Appeals Analyst represents Get Covered Illinois in Marketplace appeals, which include advanced level and complex analysis and problem-solving in the application and administration of healthcare programs within the Affordable Care Act. The position requires an advanced and integrated knowledge and competencies on the appeals regulatory and legal processes and requirements. The Marketplace Appeals Analyst, working in a high volume and data/deadline-driven environment, researches, analyzes and identifies the appropriate and relevant factors affecting program eligibility, both current and historical, in order to resolve complex issues. The problem-solving aspects of the position require complex legal analysis and frequently entail applying agency policy and federal and state law to novel factual situations, each case being highly variable.

Get Covered Illinois is the State of Illinois’s new Health Insurance Marketplace. Get Covered Illinois’s mission is to increase access, enrollment, affordability, and choice for individuals and families by connecting them to health insurance plans and savings available through the Affordable Care Act. Get Covered Illinois provides pathways to coverage through a consumer-centric online application platform, a Customer Assistance Center, localized outreach and education strategies and a network of in-person assisters embedded in communities across the state that help Illinoisans enroll in the coverage that best meets their families’ needs. Get Covered Illinois is part of the Illinois Department of Insurance and has offices in Chicago and Springfield.

Why Work for Illinois?

Working with the State of Illinois is a testament to the values of compassion, equity, and dedication that define our state. Whether you’re helping to improve schools, protect our natural resources, or support families in need, you’re part of something bigger—something that touches the lives of every person who calls Illinois home.

No matter what state career you’re looking for, we offer jobs that fit your life and your schedule—flexible jobs that provide the gold standard of benefits. Our employees can take advantage of various avenues to advance their careers and realize their dreams. Our top-tier benefits and great retirement packages can help you build a rewarding career and lasting future with the State of Illinois.

Essential Functions

• As a State-Based Marketplace Appeals Analyst, assists with appeals or Resolution Review operations and independently processes appeals or Resolution Review cases and duties related to such.  
• Provides technical expertise for the appeals or Resolution Review operations for the Marketplace.
• Performs detailed case research and analysis related to appeals and Resolution Review requests and determines eligibility for certain Illinois health care programs.
• Provides general compliance monitoring and audit support and assists with data coordination and privacy/security collaboration.
• Assists with training and staff developments to ensure compliance standards and needs are met.
• Serves as liaison between GCI’s Compliance and Program Oversight team and the Department of Insurance’s (DOI) Legal team.
• Performs other duties as required or assigned which are reasonably within the scope of the duties enumerated above.

Minimum Qualifications

• Requires knowledge, skill, and mental development equivalent to completion of four (4) years of college, preferably with coursework in business or public administration.
• Requires one (1) year of responsible administrative experience in a public or business organization, or completion of an agency approved professional management training program.

Preferred Qualifications

• Prefers one (1) year of experience dealing with administrative appeals processes.
• Prefers one (1) year of experience drafting and/or implementing compliance policies, procedures, or monitoring tools in a healthcare or public sector setting.
• Prefers at least two (2) years of experience with Marketplace eligibility in regard to appeals or compliance.
• Prefers at least two (2) years of experience with Medicaid or other government healthcare programs.
• Prefers at least two (2) years of experience attending or supporting administrative hearings, including preparing documentation, submitting evidence, and providing testimony on behalf of an agency or organization when necessary.
• Prefers at least two (2) years of experience with designing and/or implementing a compliance program in a healthcare or government setting.
• Prefers at least two (2) years of experience with general compliance monitoring activities, such as policy compliance checks, and corrective action planning.
• Prefers at least two (2) years of experience demonstrating good oral and written communication skills to express ideas clearly, concisely, and courteously across multiple audiences, including the public and internal stakeholders.
• Prefers at least two (2) years of experience coordinating with multiple internal and external stakeholders (e.g., state, and federal agencies, IT vendors) on compliance and appeals related activities.
• Prefers at least two (2) years of experience tracking and analyzing appeals trends and recommending improvements to appeals processes using performance metrics or internal dashboards.

Specialized Skills

• Requires one (1) year of experience dealing with administrative appeals processes.
• Requires one (1) year of experience drafting and/or implementing compliance policies, procedures, or monitoring tools in a healthcare or public sector setting.

Conditions of Employment

• Requires the ability to pass a background check.
• Requires ability to travel in the performance of duties, with overnight stays as appropriate.
• The conditions of employment listed here are incorporated and related to any of the job duties as listed in the job description.
• Certain provisions of the revolving door restrictions contained in 5 ILCS 430/5-45 apply to this position. As a result, the employee should be aware that if offered non-State employment during state employment or within one year immediately after ending State employment, the employee shall, prior to accepting any such non-State employment offer, notify the Office of the Executive Inspector General for the Agencies of the Illinois Governor (OEIG) or may be subject to a fine.

About the Agency

The Department of Insurance (DOI) regulates the insurance market in the State of Illinois including, but not limited to, licensing and educating insurance agents, investigating Workers Compensation fraud, and examining the operations and finances of insurance companies domiciled in the state. We are committed to protecting consumers and regulating the insurance industry with innovation and efficiency. DOI has approximately 220 employees who are split between our Chicago and Springfield offices.

State of Illinois employees enjoy a robust benefit package, including:

• Health, Life, Vision, and Dental Insurance
• 13 Paid Holidays annually, 14 on even numbered years
• 10-25 days of Paid Vacation time annually - (10 days in year one of employment)
• 12 Paid Sick Days annually (sick days carry over from year to year)
• 12 Weeks Paid Maternity/Paternity Leave
• 3 Paid Personal Days annually
• Pension Plan
• Deferred Compensation Program and other pre-tax benefit programs (Medical/Daycare)
• Flexible work schedules may be available, dependent upon position
• Tuition Reimbursement Program and Federal Public Service Loan Forgiveness Program eligibility

Visit https://www2.illinois.gov/cms/benefits/Pages/default.aspx for more information about our benefits.