Appeals Professional III (Monday - Friday)

Tmf/C2C•Austin, TX

10d•Remote

About The Position

Provides an independent second level determination based on the documentation, facts, laws, regulations, and guidelines. This position is located Remote United States.

Requirements

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
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
Resided in the United States for a minimum of three (3) years out of the last five (5) years (Per Contract Requirement)

Nice To Haves

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 directly relevant to Medicare managed care appeals or utilization management activities

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.