Medicare Clinical Appeals Reviewer, RN, PT, OT, RT

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

📋 Description

• Examine medical records and case documents.

• Compose clear, concise, and unbiased reconsideration/dispute resolution decisions that document and substantiate determinations.

• Render fair, impartial, and independent decisions based on current medical evidence, statutes, regulations, rulings, policies, and procedures for Medicare Part C appeals.

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

• Investigate federal regulations, contract policies, medical practice standards, manuals, coverage issues, medical literature, and related resources.

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

• Take part in case-specific verbal discussions.

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

• Strategize responses to statistical analysis challenges with the assistance of statisticians.

• Attend meetings and engage in workgroups as directed by management.

• Act as a subject matter expert.

• Mentor and/or train staff members.

• Conduct quality reviews and audits as necessary.

• Engage in special projects and carry out other assigned responsibilities.

⛳️ Requirements

• Active, unrestricted license in good standing as an RN, PT, RT, OT, or another qualifying licensed healthcare professional.

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

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

• Proven experience in writing or making medical necessity decisions.

• Expertise in research techniques, medical terminology, and analyzing and interpreting policies.

• Familiarity with state and federal laws and regulations.

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

• Experience with Medicare regulations, claims processing, and the medical review process.

• Capability to prioritize and organize work tasks, handle multiple tasks simultaneously, and meet deadlines.

• Skill in preparing, proofreading, and reviewing correspondence and documents for clarity and consistency.

• Strong logic and reasoning skills to identify problems, verify facts, and draw valid conclusions.

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

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

• Effective verbal and written communication skills.

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

• Integrity and ethical behavior; respect for confidentiality, business ethics, and organizational standards.

• Adherence to company policies, procedures, cybersecurity, regulatory, contractual, and accreditation requirements.

• Experience specifically 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.

• Valid driver's license with a clean and satisfactory driving record.

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

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

• Associate's degree or 60 or more credit hours toward a Bachelor's degree from an accredited college or university in healthcare or a related field.

• Additional relevant experience may be substituted for an Associate's degree on a year-for-year basis.

• Ability to work during Eastern, Central, or Mountain Time Zone business hours.

• Capacity to work in an office/cubicle environment and perform tasks such as sitting, standing, walking, bending, twisting, and/or reaching.

• Ability to work extended periods at a desk and on a computer.

• May occasionally need to lift 25 pounds.

• May require the operation of a motor vehicle and travel by motor vehicle or commercial airline.

• Overnight travel may be necessary.

🏝️ Benefits

• Fully remote work arrangement.

• Equal Employment Opportunity protections.

• Reasonable accommodation support for individuals with disabilities.