Medicare Appeals Professional with Licensed Nurse

ADP; Columbia (MD); In loco; USD 85.000 - 110.000; Tempo pieno

Descrizione del lavoro

ADP is seeking a Medicare Appeals Professional with a nursing license to join our Columbia, MD team in a full-time capacity. The role focuses on reviewing medical records, issuing clear, impartial reconsideration decisions, and ensuring compliance with applicable statutes and policies.

Responsibilities include researching regulations, addressing all appeal issues raised by beneficiaries, and mentoring staff while participating in meetings and workgroups.

Competenze

• Three years of medical dispute resolution or Medicare appeals experience.
• Licensed nurse with 3+ years of appeals experience.
• Healthcare professional with nursing, physical therapy, respiratory therapy or occupational therapy experience.
• Experience writing or making medical necessity decisions.
• Medicare managed care appeals or utilization management experience preferred.

Mansioni

• Reviews medical records and writes impartial reconsideration decisions.
• Makes sound decisions based on medical evidence, regulations, and policy.
• Responds to all appeal issues raised by beneficiaries, representatives, and providers.
• Provides fair and impartial decisions based on current evidence.
• Conducts research using federal regulations, policy, literature and related resources.
• Stays updated on regulatory and clinical practice changes.
• Participates in case discussions and workgroups.
• Mentors and trains staff; participates in quality reviews and audits as assigned.

Conoscenze

Medical dispute resolution

Medicare appeals

Clinical judgement

Nursing license

Formazione

Associate degree or 60+ credits towards Bachelor's in healthcare

Descrizione del lavoro

If you are unable to complete this application due to a disability, contact this employer to ask for an accommodation or an alternative application process.

Medicare Appeals Professional with Licensed Nurse

Full Time Entry- to Mid-Lvl IC Columbia, MD, US

30+ days ago Requisition ID: 1337

Responsibilities:

• Reviews medical records/case file, writes a reconsideration decision letter that is clear, concise, and impartial 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, and provider/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, contract manuals, coverage issues manuals, medical literature, and other related resources to complete an accurate and 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 related experience 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 or university in healthcare or related discipline Additional experience in Medicare appeals, medical review, clinical, or other related experience in a healthcare setting may be substituted for Associate's degree on a year per year basis.

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