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 relevant guidelines.

• Make decisions on appeals in alignment with Medicare laws, regulations, and established protocols.

• Assess the appropriateness of adjustments within standard systems.

• Provide professional, accurate, and timely responses to Medicare appellants.

• Prepare, proofread, and dispatch correspondence in accordance with current guidelines.

• Investigate claims processing issues and initiate corrective measures.

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

• Submit educational referrals aimed at minimizing redeterminations and facilitating claims resolution at the lowest appropriate appeal level.

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

• Identify educational and training needs and support training efforts as required.

• Communicate relevant information to both internal and external stakeholders.

• Research issues, analyze data, and resolve problems effectively.

• Process overpayment appeals as assigned.

• Maintain up-to-date knowledge of operational systems, processing instructions, CMS requirements, Joint Operating Agreement requirements, and other pertinent resources.

• Carry out additional duties and special projects as assigned.

• May oversee work activities, provide guidance on workloads, and assist with training or reporting tasks.

⛳️ Requirements

• High School Diploma or equivalent.

• At least six (6) months of relevant work experience.

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

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

• Preferred experience in Medicare claims, appeals processing, healthcare administration, customer service, or records review.

• Basic PC knowledge and capability to operate within standard business systems.

• Strong skills in prioritization, analysis, and communication.

• Ability to adapt to changes in guidelines, systems, workloads, and business requirements.

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

• Proficiency in preparing clear, accurate, and professional written correspondence.

• Ability to investigate issues, identify gaps, and propose corrective actions.

• Maintain confidentiality and manage sensitive information appropriately.

• Strong attention to detail and dedication to quality and compliance.

• Must reside within 55 miles of Rockledge, Florida.

• Availability to work Monday through Friday, with shifts scheduled between 8 am and 8 pm.

• Ability to fulfill essential physical requirements, with or without reasonable accommodation, including extended periods of sitting or standing, keyboarding, screen viewing, communication, and lifting up to 25 pounds.

🏝️ 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, determined by the number of hours worked.

• Eligibility for 401k plan for full-time employees starting on the first of the month following their hire date.

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

• Access to an Employee Assistance Program.

• Opportunity for full-time remote work.