Redetermination Examiner
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Job Description
Remote Redetermination Examiner reviewing Medicare appeals and applying CMS regulations. Supporting BAC’s innovative services for individuals with disabilities through accurate claim determinations.
Responsibilities:
- Examine incoming Medicare redetermination appeals by reviewing documentation, claim history, and applicable guidelines
- Make appeal determinations in accordance with Medicare rules, regulations, and established guidelines
- Determine whether adjustments within standard systems are appropriate
- Respond to Medicare appellants professionally, accurately, and promptly
- Prepare, proofread, and issue correspondence according to current guidelines
- Research 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 education and training needs and assist with training as necessary
- Communicate information to 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 other relevant resources
- Perform other duties and special projects as assigned
- May coordinate work activities, provide workload guidance, and support training or reporting activities
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 any 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 reside within 55 miles of Rockledge, Florida
- Availability to work Monday-Friday, with shift times between 8 am and 8 pm
- Ability to perform essential physical requirements, with or without reasonable accommodation, including extended sitting or standing, keyboarding, screen viewing, communication, and lifting up to 25 pounds
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 the number of hours worked
- 401k plan eligibility for full-time employees on the first of the month following their date of hire
- Supplemental benefits, including Accident, Critical Illness, Short Term Disability, and Hospital
- Employee Assistance Program
- Full-time remote work
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