Appeals Professional III (Weekend Work) (Part C)

Tmf/C2C•Austin, TX

17h•Remote

About The Position

This position provides an independent second level determination based on the documentation, facts, laws, regulations, and guidelines. The role involves reviewing medical records/case files, writing clear, concise, and impartial reconsideration decision letters that support the determination made, and documenting the review. The Appeals Professional III makes sound, independent decisions based on medical evidence in accordance with statutes, regulation, rulings, and policy. They are responsible for responding to and ensuring that all appeal issues raised by the beneficiary/patient, representative, and provider/supplier have been addressed, providing a fair and impartial decision based on current evidence, regulations, policies, and procedures. This role requires conducting 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. This is a part-time, remote position located in the United States, requiring weekend work (both Saturday and Sunday).

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.
Prior experience working on the Part C Qualified Independent Contractor (QIC) effort.
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.