Appeals Representative

Are you interested in joining a team of experienced healthcare experts and have the ability to shape and transform the healthcare delivery system? At our family of companies, everything we do is to help improve the lives of the nearly 12 million Medicare beneficiaries we serve and 700,000 health care providers who care for them. It is our goal to help create a better health experience for all consumers. Join our winning culture and help transform Medicare for the millions of people who rely on its services.

Benefits info:

• Medical, dental, vision, life and supplemental insurance plans effective the first day of the month following date of hire
• Short- and long-term disability benefits
• 401(k) plan with company match and immediate vesting
• Free telehealth benefits
• Free gym memberships
• Employee Incentive Plan
• Employee Assistance Program
• Rewards and Recognition Programs
• Paid Time Off and Paid Sick Leave

SUMMARY STATEMENT
Team members are accountable for conducting a review of Medicare Part A or B claims on services questioned on appeal by a provider, facility, beneficiary, Centers for Medicaid and Medicare Services (CMS) or other interested parties using multiple computer applications. Incumbents render appeals decisions based on research of the initial claim processing activity, documented procedures and policies and information supplied with the appeal request and respond to the appeal in the form of an adjustment to payment, refund request for overpayment or a written response upholding the original processing of the service.

ESSENTIAL DUTIES & RESPONSIBILITIES
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. This list of essential job functions is not exhaustive and may be supplemented as necessary.

Respond timely to Medicare inquiries that constitute an appeal or reopening of an initial claim determination. (90%)

• Researches electronic files and imaged records and/or accesses the appropriate external systems such as Multi-Carrier System (MCS), Fiscal Intermediary Standard System (FISS), Medicare Appeals System (MAS) as well as Microsoft Windows applications including Excel files and Word documents.
• Reads and interprets processing guidelines, determines the accuracy of the original claim determination and takes the necessary actions to finalize the case file. Performs claim correction activity of the initial claim determination when an additional payment or a reduction in payment correction is necessary.
• Reviews additional documentation (e.g., office notes, test results, medical records, etc.) submitted with the request to determine if this information should be forwarded to a clinician for additional consideration or utilize the additional documentation to make the redetermination decision.

Resolves adjustment claims which suspend due to system edits/audits or have been returned to the department from entities conducting subsequent levels of review. (10%)

Performs other duties as the supervisor may, from time to time, deem necessary.

REQUIRED QUALIFICATIONS

• High School diploma or GED
• 2 years’ experience utilizing research skills in reading and interpreting information
• PC experience in Microsoft Windows or similar environment – includes Word, Excel, PowerPoint, etc.
• Demonstrated verbal and written communication skills
• Demonstrated customer service skills
• Demonstrated ability to make independent decisions relating to claims processing accuracy relying on various on-line reference tools

PREFERRED QUALIFICATIONS

• Sound research and decision-making skills to respond to the inquiry in accordance with Medicare procedures and guidelines
• Demonstrated knowledge of Medicare policies and benefits, internal processing instructions, as well as medical terminology
• Medicare claims processing experience or a medical background
• Knowledge of Medicare processing systems

This opportunity is open to remote work in the following approved states: AL, FL, GA, ID, IN, IO, KS, LA, MS, NE, NC, ND, OH, PA, SC, TN, TX, UT, WV, WI, WY. Specific counties and cities within these states may require additional approval. In FL, PA, TX and WI, in-office and hybrid work may also be available.

The Federal Government and the Centers for Medicare & Medicaid Services (CMS) may require applicants to have lived in the United States for a minimum of three (3) years out of the last five (5) years to be employed with the Company. These years of residence do not have to be consecutive.