Medicare Appeals Professional with Licensed nurse

Position Purpose: 

Performs complex (senior-level) work. Provides dissatisfied parties to a Medicare appeal the opportunity to present documentation to demonstrate why an appeal should be allowed. Provides an independent second level determination based on the documentation, facts, laws, regulations, and guidelines. Works under general supervision, with moderate latitude for the use of initiative and independent judgment. 

Essential Responsibilities: 

• Reviews medical records/case file, writes a reconsideration decision letter that is clear, concise, and impartial and supports the determination made, and documents review.
• Makes sound, independent decisions based on medical evidence in accordance with statutes, regulation, rulings, and policy.
• Responds to and ensures that all appeal issues raised by the beneficiary/patient, representative, and provider/supplier have been addressed.
• Provides a fair and impartial decision based on current evidence, regulations, policies, and procedures.
• Conducts research using online federal regulations, contract policy, standards of medical practice, contract manuals, coverage issues manuals, medical literature, and other related resources to complete an accurate and well-supported decision.
• Stays abreast of changes in regulations, medical and healthcare practices, policies and procedures.
• Participates in case specific verbal discussions.
• Conducts reviews of appeals/disputes with multiple beneficiaries/services in one case.
• Plans responses to statistical analysis challenges with assistance from statisticians.
• Attends meetings and participates in workgroups at the direction of management.
• Conducts quality reviews, as needed.
• Serves as a subject matter expert.
• Mentors and/or trains staff.
• May conduct quality reviews and audits.
• Participates in special projects and performs other duties as assigned.

Minimum Qualifications 
Education 
 Associate's degree or 60 or more credit hours towards a Bachelor’s degree from an accredited college or university in healthcare or related discipline Additional experience in Medicare appeals, medical review, clinical, or other related experience in a healthcare setting may be substituted for Associate’s degree on a year per year basis. (Experience requirements may be satisfied by full-time experience or the prorated part-time equivalent.)

Experience 

• Three (3) years of medical dispute resolution or Medicare appeals, medical review, clinical, or related experience in a healthcare setting
• Healthcare Professional with Nursing, Physical Therapy, Respiratory Therapy or Occupational Therapy experience
• Demonstrated experience writing or making medical necessity decisions
• Experience directly relevant to Medicare managed care appeals or utilization management activities, preferred
• Resided in the United States for a minimum of three (3) years out of the last five (5) years? (Per Contract Requirement)

Knowledge, Skills and Abilities 

Considerable knowledge of 

• Research techniques
• Medical terminology
• Medicare program, including coverage and payment rules
• Medicare regulations, claims administration, and medical review processes
• Applicable laws, rules and regulations

Expert skill in 

• Preparing correspondence/documents using correct spelling, grammar and punctuation; proofreading and reviewing documents for clarity and consistency
• Researching, analyzing and interpreting policies and state and federal laws and regulations

Proficient skill in 

• Prioritizing and organizing work assignments
• The use of personal computers and applicable programs, applications and systems

 Ability to 

• Multitask and meet deadlines
• Exercise logic and reasoning to define problems, establish facts and draw valid conclusions
• Make decisions that support business objectives and goals
• Identify and resolve problems or refer issues appropriately
• Communicate effectively verbally and in writing
• Adapt to the needs of internal and external customers
• Show integrity and ethical behavior; respect confidentiality, business ethics and organizational standards
• Assures compliance with company policies, procedures, and guidelines including cybersecurity, regulatory, contractual and accreditation entities

Residency Requirement
 Must be eligible to obtain and maintain a Public Trust clearance. Candidates must have resided in the United States for at least three (3) of the last five (5) years.

Residency Requirement:

Candidate must be able to obtain Public Trust clearance and must have lived in the United States for at least three (3) out of the last five (5) years. 

Salary & Benefits Information: 

• The actual salary offer will carefully consider a wide range of factors, including your skills, qualifications, experience, and location. 
• C-HIT offers Healthcare Benefits, Remote Working Options, Paid Time Off, PTO cash-out, Training/Certification opportunities, Healthcare Savings Account & Flexible Savings Account, Paid Life Insurance, Short-term & Long-term Disability, 401K Match, Employee Assistance Program, Paid Holidays, and much more perks and Voluntary benefits! 
• Employees of C-HIT shall, as an enduring obligation throughout their term of employment, adhere to all information security requirements as documented in company policies and procedures. 

C-HIT, a CMMI Maturity Level 5 company, focuses on delivering information technology and professional services to Federal and State agencies. 

“C-HIT is an EOE, including disability and veterans”