Appeals Professional (Part C)

Tmf/C2C • Austin, TX

13h • Remote

About The Position

Provides dissatisfied parties to a Medicare appeal the opportunity to present documentation or evidence to demonstrate why an appeal should be allowed. Provides an independent second level determination based on the documentation, facts, laws, regulations, and guidelines.

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
• One (1) year of Medicare appeals, medical review, clinical, healthcare regulatory interpretation/application, healthcare compliance or related experience in a healthcare setting
• 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.
• Medicare Part C related appeals activities

Responsibilities

• Reviews medical records/case file, writes a decision 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 issues raised by the beneficiary, representative, supplier, and provider 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.

Benefits

• Medical, dental, vision, life, accidental death and dismemberment, and short and long-term disability insurance
• Section 125 plan
• 401K
• Competitive salary
• License/credentials reimbursement
• Tuition Reimbursement

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: Associate degree