Medicare Appeals Professional with Licensed Nurse

C-HIT; Columbia (MD); On-site; USD 70,000 - 90,000; Full time

Job summary

C-HIT is seeking an experienced reviewer to assess medical records and write clear reconsideration decisions for Medicare appeals. You will base determinations on current evidence, regulations, and policies, ensuring impartiality and sound clinical judgment.

The role requires 3+ years in medical dispute resolution, nursing or healthcare background, and strong research skills to address issues raised by beneficiaries, representatives, or providers.

Qualifications

• Three years of medical dispute resolution or Medicare appeals experience.
• Licensed nurse with 3+ years appeals experience.
• Healthcare professional with Nursing, PT, RT, or OT background.
• Experience writing or making medical necessity decisions.

Responsibilities

• Review medical records and write reconsideration decisions that are clear, concise, and impartial.
• Address all appeal issues raised by beneficiaries, representatives, and providers.
• Research regulations, policy, and medical literature to support decisions.
• Mentor staff and participate in meetings and quality reviews.

Skills

Medical dispute resolution

Medicare appeals

Clinical decision making

Policy interpretation

Education

Associate's degree or 60+ credits

Job description

• 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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