Medicare Appeals Professional with Licensed Nurse

 Responsibilities: 

• Reviews medical records/case file, writes a reconsideration decision letter that is clear, concise, andimpartial and supports the determination made, and documents review.
• Makes sound, independent decisions based on medical evidence in accordance with statutes, regulation,rulings, and policy.
• Responds to and ensures that all appeal issues raised by the beneficiary/patient, representative, andprovider/supplier have been addressed.
• Provides a fair and impartial decision based on current evidence, regulations, policies, and procedures.
• Conducts research using online federal regulations, contract policy, standards of medical practice, contractmanuals, coverage issues manuals, medical literature, and other related resources to complete an accurateand well-supported decision.
• Stays abreast of changes in regulations, medical and healthcare practices, policies and procedures.
• Participates in case specific verbal discussions.
• Conducts reviews of appeals/disputes with multiple beneficiaries/services in one case.
• Plans responses to statistical analysis challenges with assistance from statisticians.
• Attends meetings and participates in workgroups at the direction of management.
• Conducts quality reviews, as needed.
• Serves as a subject matter expert.
• Mentors and/or trains staff.
• May conduct quality reviews and audits.
• Participates in special projects and performs other duties as assigned.

Experience Must:

• Three (3) years of medical dispute resolution or Medicare appeals, medical review, clinical, or relatedexperience in a healthcare setting
• Licensed nurse with 3 or more years of experience conducting appeals
• Healthcare Professional with Nursing, Physical Therapy, Respiratory Therapy or Occupational Therapy experience
• Demonstrated experience writing or making medical necessity decisions
• Experience directly relevant to Medicare managed care appeals or utilization management activities,preferred

Minimum Education Qualifications:

Associate's degree or 60 or more credit hours towards a Bachelor’s degree from an accredited college oruniversity in healthcare or related disciplineAdditional experience in Medicare appeals, medical review, clinical, or other related experience in ahealthcare setting may be substituted for Associate’s degree on a year per year basis. 

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