Supervisor (Clinical Adjudication) Weekday Evening Shift - Flexible Scheduling (Part C)

Tmf/C2C • Austin, TX

13h • 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. 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.

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
• 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

• 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.
• 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