Medicare Appeals Specialist

Broadway Ventures•Amite, LA

20h

About The Position

At Broadway Ventures, we transform challenges into opportunities with expert program management, cutting-edge technology, and innovative consulting solutions. As an 8(a), HUBZone, and Service-Disabled Veteran-Owned Small Business (SDVOSB), we empower government and private sector clients by delivering tailored solutions that drive operational success, sustainability, and growth. Built on integrity, collaboration, and excellence, we’re more than a service provider—we’re your trusted partner in innovation. Redetermination (Appeals) Specialist Job summary The Redetermination (Appeals) Specialist adjudicates first-level Medicare appeals on a post-claim basis, reviewing redetermination requests against Medicare regulations, claims processing rules, and appeal guidelines to reach and document a correct determination. The role produces the Medicare Redetermination Notice (MRN) communicating each decision, determines financial liability, and supports the department in meeting CMS performance metrics.

Requirements

Must have lived in the United States at least 3 out of the last 5 years. This is a CMS requirement.
High school diploma or equivalent.

Nice To Haves

2 or more years recent health insurance experience (customer service, claims processing, or medical billing) dealing with coverage and medical necessity determinations.
Knowledge of MCS/FISS and the MAS systems.

Responsibilities

Receive, review, and provide written responses (Medicare Redetermination Notice [MRN]) to requests from customers on a post-claim basis in first step of Medicare appeal process.
Apply knowledge of Medicare regulations, claims processing, and appeal guidelines to determine proper resolution of requests.
Obtain and review system and hard copy documentation and medical notes. Review and compare processed claims for required coding elements to establish medical necessity, frequency of service, and accurate fee determinations.
Refer cases to appeal nurses when clinical judgment is required to make decision or is required by audit.
Determine appropriate resolution to appeal request and adjudicate redetermination decision by resolving all error edits and audits, changing codes, entering allowable amounts, working with other units, pending requests for development, and adjudicating claim to completion.
Determine appropriate financial liability for decision.
Develop and complete explanations of decision for MRN decision letter through use of various letter templates, policy information, and input from medical staff.
Use various technological applications, such as Word, web portal, or electronic letter writing system to generate and revise determination notifications.
Resolve pended/aged cases, log all requests, and document/update clearly on-line comment file with detail of action taken.
Research electronic redetermination work processes and reference manuals throughout process of making determinations regarding requests.
Correspond with Medicare customers to clarify information for claim determination and explain claim adjudication.
Assist and educate providers on Medicare regulations by utilizing CMS guidelines, publications, and reference materials to ensure correct claim submission. Refer recurrent provider errors to Provider Education for further contact.
Identify, verify, calculate, and setup overpayment situations. Assist in reporting and recoupment of overpayments.
Identify and refer potential fraudulent providers and/or beneficiaries to Complaint Screening.
Refer and forward mis-directed correspondence and unusual claims aberrancies to appropriate area for handling.
Assist department in meeting CMS performance metrics and minimum quality and quantity standards. Provide back-up for completing staff responsibilities as needed.
Provide technical assistance by identifying and reporting system problems, testing new enhancements, and other changes as released.