Appeals Professional III

J29, Inc•Millersville, TN

10d

About The Position

J29 is an employee centered healthcare management consulting company that specializes in processing, reviewing, and analyzing medical claims, records, disputes, and audits. Established in 2017, J29 prides itself on its employee centric culture and high employee retention rates that allow us to ensure that we are creating a working environment that prioritizes the employee experience. Our team brings corporate performance that stretches to various areas where we can provide our clinical, healthcare policy, and compliance expertise through our support to health and human service programs at the State, Federal, and Commercial levels. 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.

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 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.)
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)
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

Nice To Haves

Experience directly relevant to Medicare managed care appeals or utilization management activities, preferred

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.