Medicare Appeals Professional with Licensed Nurse

C-HIT•Columbia, MD

About The Position

This role involves reviewing medical records and case files to write clear, concise, and impartial reconsideration decision letters that support the determination made. The professional will document their reviews and make independent decisions based on medical evidence, adhering to 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 a fair and impartial decision based on current evidence, regulations, policies, and procedures. The professional will conduct research using various online resources, including federal regulations, contract policy, standards of medical practice, and medical literature, to ensure accurate and well-supported decisions. Staying updated on changes in regulations, medical practices, and policies is crucial. The role also includes participating in case-specific verbal discussions, reviewing appeals with multiple beneficiaries or services, planning responses to statistical analysis challenges, attending meetings, and participating in workgroups. Additional duties may include 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
Experience directly relevant to Medicare managed care appeals or utilization management activities

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
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