Supervisor (Clinical Adjudication) (Part C)

Tmf/C2C • Austin, TX

14h • Remote

About The Position

Provides dissatisfied patient/beneficiaries and/or providers the opportunity to present documentation to demonstrate why an appeal/dispute should be allowed. Provides an independent second level determination/dispute resolution 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
• 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.
• Five (5) years conducting or overseeing Medicare appeals, medical review, or utilization management of Medicare claims.
• Supervisory or Team Lead Healthcare Professional with demonstrated experience writing, making, or overseeing Medicare related medical necessity decisions
• Nursing, Physical Therapy, Respiratory Therapy or Occupational Therapy experience

Nice To Haves

• Conducting or overseeing Medicare Part C related appeals activities

Responsibilities

• Oversees and participates in formal pre-decisional appellant/requestor/provider discussions for the purpose of allowing the appellant/requestor/provider to be heard and submit additional documentation; or, engages the parties in other types of communication in order to obtain information and a more complete understanding of the appeal/dispute issues.
• Oversees and reviews medical records/case file, writes a reconsideration that is clear, concise, and impartial and supports the determination made, and documents review.
• Oversees and makes sound, independent decisions based on medical evidence in accordance with statutes, regulation, rulings, and policy.
• Oversees, responds to and ensures that all appeal issues raised by the beneficiary/patient, representative, and provider/supplier have been addressed.

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: Manager
• Education Level: Associate degree