Redetermination Examiner
Posted 4ds ago
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Job Description
Medicare Redetermination Examiner reviewing claims, documentation, and CMS guidelines for BAC, a provider of innovative disability services. Processing appeals and communicating accurate determinations to Medicare appellants.
Responsibilities:
- Examine incoming Medicare redetermination appeals by reviewing documentation, claim history, and applicable guidelines
- Conduct redetermination reviews in accordance with Medicare rules, regulations, and established guidelines
- Determine whether adjustments within standard systems are appropriate
- Respond to Medicare appellants professionally, timely, and accurately
- Prepare, proofread, and issue correspondence according to current guidelines
- Research and identify claims processing deficiencies and initiate corrective responses
- Evaluate documentation, claim history, and policy criteria for accurate and compliant appeal processing
- Submit educational referrals to reduce redeterminations and support claims resolution at the lowest appropriate appeal level
- Assist with writing, reviewing, and updating processing guidelines
- Identify internal or external education and training needs and assist with training
- Communicate information to appropriate internal and external parties
- Research issues, analyze information, and solve problems
- Process overpayment appeals as assigned
- Maintain current knowledge of working systems, processing instructions, CMS requirements, Joint Operating Agreement requirements, and relevant resources
- May coordinate work activities, provide workload guidance, and support training or reporting activities
- Perform other duties and special projects as assigned
- No overnight or out-of-area travel expected; local movement within local sites required for inspections, meetings, incident response, and contract operations
Requirements:
- High School Diploma or equivalent
- Minimum of six (6) months of work-related experience
- Must successfully pass all required pre-employment screenings, including a drug screening
- Ability to obtain and maintain required 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 preferred
- General PC knowledge and ability to work within standard business systems
- Strong prioritization, analytical, and communication skills
- Ability to adapt to changes in guidelines, systems, workloads, and business needs
- Ability to review documentation and apply policies, procedures, and guidelines accurately
- Ability to prepare clear, accurate, and professional written correspondence
- Ability to research issues, identify deficiencies, and recommend corrective responses
- Ability to maintain confidentiality and handle sensitive information appropriately
- Strong attention to detail and commitment to quality and compliance
- Must be able to perform established essential functions, with or without reasonable accommodation
- Must be able to sit or stand for extended periods and perform computer-based work
- Must be able 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 periods
- 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 comply with company safety policies, information security requirements, confidentiality standards, and established procedures
Benefits:
- Free medical, dental, and vision insurance for employees
- Medical opt-out plan available for qualified employees
- Paid holidays and sick time
- Paid vacation available after one year of employment, based on hours worked
- 401(k) plan eligibility for full-time employees on the first of the month following date of hire
- Supplemental benefits, including Accident, Critical Illness, Short Term Disability, and Hospital
- Employee Assistance Program
- Remote work option
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