Appeals Professional III – Licensed Clinician

This is a fully remote position, open to applicants in United States.

📋 Description

• Review medical records and case files.

• Compose clear, concise, and unbiased reconsideration decision letters and document evaluations.

• Make autonomous decisions grounded in medical evidence, statutes, regulations, rulings, and policy.

• Address all appeal concerns raised by beneficiaries/patients, representatives, and providers/suppliers.

• Conduct research utilizing federal regulations, contract policies, medical-practice standards, manuals, medical literature, and related materials.

• Remain updated on changes in regulations, healthcare practices, policies, and procedures.

• Engage in case-specific verbal discussions.

• Review appeals/disputes that encompass multiple beneficiaries or services within a single case.

• Plan responses to statistical-analysis challenges with support from statisticians.

• Attend meetings and contribute to management-directed workgroups.

• Conduct quality reviews and audits as necessary.

• Act as a subject matter expert.

• Mentor and/or train staff members.

• Participate in special projects and fulfill other assigned responsibilities.

⛳️ Requirements

• A minimum of three (3) years of experience in medical dispute resolution, Medicare appeals, medical review, clinical roles, or similar healthcare positions.

• Experience in Nursing, Physical Therapy, Respiratory Therapy, or Occupational Therapy.

• Proven experience in writing or making medical necessity determinations.

• Proficient in research methodologies and medical terminology.

• Ability to analyze and interpret policies, alongside knowledge of state and federal laws and regulations.

• Working knowledge of the Medicare program, including coverage and payment regulations.

• Familiarity with Medicare regulations, claims processing, the medical review process, and relevant laws, rules, and regulations.

• Capability to prioritize and organize tasks, multitask, and meet deadlines.

• Skilled in preparing and proofreading correspondence and documents with correct spelling, grammar, punctuation, clarity, and consistency.

• Strong logic and reasoning abilities to identify issues, verify facts, and reach sound conclusions.

• Experience in making decisions that align with business objectives and goals.

• Ability to identify and resolve issues or refer them appropriately.

• Effective verbal and written communication skills.

• Capacity to adapt to the needs of internal and external customers.

• Commitment to integrity, ethical behavior, confidentiality, business ethics, and organizational standards.

• Ability to adhere to cybersecurity, regulatory, contractual, and accreditation requirements.

• Experience directly relevant to Medicare managed care appeals or utilization management activities is preferred.

• Must have lived in the United States for at least three (3) years out of the last five (5) years.

• Must hold a valid driver's license with a clear and satisfactory driving record.

• Ability to obtain and maintain public trust clearance and customer approval.

• Must be legally authorized to work in the United States without employer sponsorship, now or in the future.

• An Associate's degree or 60 or more credit hours towards a Bachelor's degree from an accredited college or university in healthcare or a related field, with additional relevant experience replacing education year for year.

• Ability to work during Eastern, Central, or Mountain Time Zone business hours and on a rotating schedule including weekends and holidays.

• Ability to work in an office/cubicle environment, sit for extended periods, operate a computer, and occasionally lift 25 pounds.

• Capability to operate a motor vehicle and travel by car or commercial airline, including potential overnight travel.

🏝️ Benefits

• Remote position

• Travel may be less than 5% annually

• Equal Employment Opportunity Employer

• Reasonable accommodation for applicants with disabilities

• Drug-free workplace

• E-Verify