Redetermination Examiner

Noridian Healthcare Solutions • Fargo, ND

193d • $17 - $23

About The Position

The Redeterminations Examiner is responsible for examining incoming Medicare Redetermination appeals through a review of documentation to make appeal determinations. This position determines if adjustments within standard systems are in accordance with established guidelines and policies and responds to Medicare appellants ensuring quality administration of Centers for Medicare and Medicaid Services (CMS) regulations and continuous, proactive customer satisfaction.

Requirements

• High School diploma or GED
• 6 months' work-related experience
• General PC knowledge
• Prioritization skills
• Strong communication skills
• Strong analytical skills
• Ability to adapt to changes
• 1-year redetermination processing experience
• Knowledge of medical terminology, Claims Processing Timelines (CPT), Healthcare Common Procedure Coding System (HCPCS) and ICD coding

Nice To Haves

• Ability to read, hear, speak, keyboard, reason, communicate effectively and problem solve
• Office Environment experience
• Infrequent lifting to 15 pounds
• Infrequent stooping

Responsibilities

• Conducts redetermination reviews per Medicare rules and regulations
• Responds to incoming appeals from Medicare appellants in a professional, timely, and accurate manner, including letter writing and proofreading with attention to detail following current guidelines
• Researches and identifies claims processing deficiencies and initiates corrective response
• Evaluates all documentation and history needed to determine if it meets outlined policy criteria to ensure accurate and compliant processing in accordance with CMS guidelines
• Submits educational referrals as necessary to decrease redeterminations and allow claims to pay at the lowest level of appeal
• Assists in writing and updating processing guidelines
• Identifies internal/external education and/or training needs, communicates findings, and assists in training if necessary
• Communicates information to appropriate internal and external parties in a timely manner
• Problem solves and researches effectively
• Processes overpayment appeals as needed
• Maintains up-to-date knowledge of working systems, processing instructions, and other relevant resources to ensure efficient and accurate appeal processing
• Maintains knowledge of CMS and Joint Operating Agreement (JOA) requirements
• Performs other duties as assigned

Benefits

• Health, Dental and Vision Insurance
• Voluntary Insurance Plans
• Health Savings and Flexible Spending Accounts
• 401k and Company Match
• Company-paid Life Insurance
• Education Assistance Program
• Paid Sick Leave
• Paid Holidays
• Increasing PTO Accrual Plan
• Medical/Parental/Disability Leave
• Workers Compensation
• Retiree Benefits
• Severance Package
• Employee Assistance Program
• Financial and Health Wellness Benefits
• Casual Dress
• Open Office Setting
• Online Learning System

What This Job Offers

• Job Type: Full-time
• Career Level: Entry Level
• Industry: Administration of Human Resource Programs
• Education Level: High school or GED