Medicare Appeals Professional with Licensed Nurse

C-HIT•Columbia, MD

21h

About The Position

This role involves reviewing medical records and case files to write clear, concise, and impartial reconsideration decision letters that support determinations made. The professional will make sound, independent decisions based on medical evidence in accordance with statutes, regulations, rulings, and policy. A key aspect of the role is ensuring all appeal issues raised by beneficiaries, representatives, and providers are addressed, providing fair and impartial decisions based on current evidence, regulations, policies, and procedures. The professional will conduct research using various online resources to support decisions and stay updated on changes in regulations, medical practices, and policies. Responsibilities also include participating in verbal discussions, conducting reviews of appeals with multiple beneficiaries/services, planning responses to statistical analysis challenges, attending meetings, conducting quality reviews, serving as a subject matter expert, mentoring and training staff, and participating in special projects.

Requirements

Three (3) years of medical dispute resolution or Medicare appeals, medical review, clinical, or related experience in a healthcare setting
Licensed nurse with 3 or more years of experience conducting appeals
Healthcare Professional with Nursing, Physical Therapy, Respiratory Therapy or Occupational Therapy experience
Demonstrated experience writing or making medical necessity decisions

Nice To Haves

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.
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.