Redetermination Examiner

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

📋 Description

• Review incoming Medicare redetermination appeals by assessing documentation, claim history, and applicable guidelines.

• Perform redetermination evaluations in line with Medicare rules, regulations, and established protocols.

• Assess the appropriateness of adjustments within standard systems.

• Engage with Medicare appellants in a professional, timely, and precise manner.

• Draft, proofread, and issue correspondence in accordance with current guidelines.

• Investigate and identify claims processing deficiencies, initiating corrective measures as needed.

• Analyze documentation, claim history, and policy criteria to ensure accurate and compliant appeal processing.

• Submit educational referrals to minimize redeterminations and facilitate claims resolution at the most appropriate appeal level.

• Aid in writing, reviewing, and updating processing guidelines.

• Recognize internal or external educational and training needs and support training efforts.

• Relay information to relevant internal and external stakeholders.

• Investigate issues, analyze data, and resolve problems.

• Process overpayment appeals as assigned.

• Keep abreast of current knowledge regarding working systems, processing instructions, CMS requirements, Joint Operating Agreement requirements, and relevant resources.

• May coordinate work activities, provide workload direction, and assist with training or reporting tasks.

• Execute additional duties and special projects as assigned.

• No overnight or out-of-area travel is expected; local travel within local sites is required for inspections, meetings, incident responses, and contract operations.

⛳️ Requirements

• High School Diploma or equivalent.

• A minimum of six (6) months of relevant work experience.

• Must successfully complete all required pre-employment screenings, including a drug test.

• Ability to obtain and maintain necessary access approvals, credentials, or background clearances applicable to the assigned contract or work location.

• Experience with Medicare claims, appeals processing, healthcare administration, customer service, or records review is preferred.

• General PC proficiency and capability to work within standard business systems.

• Strong prioritization, analytical, and communication abilities.

• Capacity to adapt to changes in guidelines, systems, workloads, and business needs.

• Ability to review documentation and accurately apply policies, procedures, and guidelines.

• Competence in preparing clear, precise, and professional written correspondence.

• Skill in researching issues, identifying deficiencies, and suggesting corrective actions.

• Ability to maintain confidentiality and properly manage sensitive information.

• Keen attention to detail and a commitment to quality and compliance.

• Must be capable of performing established essential functions, with or without reasonable accommodation.

• Must be able to sit or stand for prolonged periods and engage in computer-based tasks.

• Must have the ability to use hands and fingers for keyboarding, data entry, document review, and office tasks.

• Must be able to view computer screens, reports, electronic records, and written materials for extended durations.

• Must be able to communicate verbally and in writing with supervisors, coworkers, customers, and stakeholders.

• Must be able to lift, carry, or move standard office materials and equipment weighing up to 25 pounds.

• Must adhere to company safety policies, information security protocols, confidentiality standards, and established procedures.

🏝️ Benefits

• Complimentary medical, dental, and vision insurance for employees.

• Medical opt-out plan available for eligible employees.

• Paid holidays and sick leave.

• Paid vacation available after one year of employment, based on hours worked.

• Eligibility for 401(k) plan for full-time employees on the first day of the month following the date of hire.

• Supplemental benefits, including Accident, Critical Illness, Short Term Disability, and Hospital coverage.

• Employee Assistance Program.

• Option for remote work.