Reconsideration Analyst III

TMF Health Quality Institute; United States; Hybrid; USD 42,000 - 60,000; Full time

Benefits offered by this job

Medical insurance

Dental insurance

Vision insurance

Life insurance

AD&D insurance

Short-term disability

Long-term disability

Section 125 plan

401K

Tuition Reimbursement

Job summary

TMF Health Quality Institute is seeking a remote, second-level non-medical appeals specialist to render fair, well-supported decisions for beneficiaries, suppliers, and providers. You will review evidence, apply regulations, and ensure privacy and proper release of documents.

The role involves researching federal regulations, policy materials, and payer guidelines, with emphasis on clear writing, accurate overpayment calculations, and handling a high-volume of cases from a nationwide network.

Qualifications

• Three (3) years of general office experience.
• Two (2) years high volume of customer calls, appeals, or billing.
• Resided in the United States for a minimum of three (3) years out of the last five (5) years (Per Contract Requirement)

Responsibilities

• Writes a reconsideration decision that is clear and supports the determination made.
• Ensures that all appeal issues raised by the beneficiary, representative, supplier, and/or provider have been addressed.
• Provides a fair and impartial decision based on current evidence, regulations, policies, and procedures.
• Ensures all documents are releasable and do not violate any Privacy Act provisions.
• Organizes documents by dates of service relevant to the charges, research denials and regulations used and ensure that any overpayment calculation is correct.
• Conducts research using online federal regulations, contract policy, standards of medical practice, contractor manuals, coverage manuals, and other related resources to complete an accurate and well-supported decision.

Skills

General office experience

Customer service

Billing knowledge

Education

High School Diploma or equivalent

Job description

*This position is located Remote, Anywhere*

*Due to being a federal contractor, you may be subject to obtaining and maintaining a public trust security clearance from the federal government. *

Position Purpose:

Makes second level non-medical appeal decisions for beneficiaries, supplies, or providers. This may include cases dismissed by a contractor, Medicare Secondary Payer (MSP) recovery appeals, or Expedited appeals.

• Writes a reconsideration decision that is clear and supports the determination made.
• Ensures that all appeal issues raised by the beneficiary, representative, supplier, and/or provider have been addressed.
• Provides a fair and impartial decision based on current evidence, regulations, policies, and procedures.
• Ensures all documents are releasable and do not violate any Privacy Act provisions.
• Organizes documents by dates of service relevant to the charges, research denials and regulations used and ensure that any overpayment calculation is correct.
• Conducts research using online federal regulations, contract policy, standards of medical practice, contractor manuals, coverage manuals, and other related resources to complete an accurate and well-supported decision.

Minimum Qualifications

Education

• High School Diploma or equivalent

Experience

• Three (3) years of general office experience
• College education or technical training in administration, business, or related areas may be substituted for experience on a year per year basis. (Education requirements may be satisfied by full-time education or the prorated part-time equivalent.)
• Two (2) years high volume of customer calls, appeals, or billing
• Resided in the United States for a minimum of three (3) years out of the last five (5) years (Per Contract Requirement)

C2C offers an excellent benefits package, including:

• Medical, dental, vision, life, accidental death and dismemberment, and short and long-term disability insurance
• Section 125 plan
• 401K
• Tuition Reimbursement

EOE Vet/Disability

Equal Opportunity Employer/Protected Veterans/Individuals with Disabilities

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