REMOTE ** Determinations Specialist

EXAMWORKS COMPLIANCE SOLUTIONS LLC; Lawrenceville (GA); Remote; USD 60,000 - 85,000; Full time

Job summary

EXAMWORKS COMPLIANCE SOLUTIONS LLC seeks a Determinations Specialist to analyze CMS determination letters and advocate for accurate Medicare Set-Aside recommendations. You will leverage clinical knowledge, research skills, and strong communication to support compliant MSA outcomes for clients.

The role requires MSCC certification or strong CMS knowledge, experience in MSA production, and a commitment to HIPAA compliance. Excellent analytical and written communication skills are essential.

Qualifications

• MSCC certification preferred.
• Strong knowledge of WCMSA Reference Guide and CMS guidelines.
• 12+ months in an MSA production environment or related experience.
• Prior customer service experience required.
• Baseline HIPAA knowledge and compliance.

Responsibilities

• Evaluate CMS determination letters for accuracy.
• Identify discrepancies and conduct targeted research.
• Advocate for accurate Medicare Set-Aside recommendations.
• Collaborate with clients to ensure compliant MSA outcomes.
• Maintain confidentiality and manage time efficiently.

Skills

Analytical skills

Research

Problem solving

Written communication

Verbal communication

Attention to detail

Time management

Discretion/confidentiality

Education

High school diploma or equivalent

Associate’s degree preferred

Tools

Microsoft Word

Outlook

Excel

Adobe

Internet

Job description

Are you a Medicare Set-Aside expert who enjoys analyzing complex cases, solving problems, and making a meaningful impact? ECS is seeking a highly skilled Determinations Specialist to join our team and play a critical role in advocating for accurate Medicare Set-Aside (MSA) recommendations and ensuring compliance with CMS guidelines.In this position, you'll leverage your clinical knowledge, analytical expertise, and critical thinking skills to evaluate CMS determination letters, identify discrepancies, conduct research, and support successful MSA outcomes for our clients. If you're passionate about navigating complex regulatory requirements and collaborating with clients to achieve the best possible results, we'd love to hear from you.Schedule: Monday-Friday, 8:00 AM-5:00 PMRequired QualificationsMSCC (Medicare Set-Aside Certified Consultant) certification is preferred.Strong knowledge of the WCMSA Reference Guide and CMS Medicare coverage guidelines is preferred.Exceptional analytical, research, and problem-solving skillsStrong written and verbal communication abilitiesMedicare Set-aside Certified Consultant (MSCC)Medicare Set-aside (MSA)Centers for Medicare & Medicaid Services (CMS)Workers' Compensation Review Contractor (WCRC)MSP ComplianceMedicare Secondary Payer (MSP)Education and/or ExperienceHigh school diploma or equivalent required. Associate’s degree preferred. Prior customer service experience required. A minimum of twelve months MSA production environment experience or related experience is preferred.QUALIFICATIONSPrevious Customer Service experience required. Minimum 12 months production environment experience or related experience preferred.Adequate knowledge of 3rd party/COB (Coordination of Benefits) / insurance verification / medical billing (ICD-9/CPT) experience preferred.Competency in mathematics, business terminology, clerical skills and time management.Must possess complete knowledge of general computers, fax, copier, scanner, and telephone.Must be knowledgeable of multiple software programs, including but not limited to Microsoft Word, Outlook, Excel, Adobe and the Internet.Must have a full understanding of HIPAA regulations and compliance.Ability to follow instructions and respond to managements’ directions accurately.Demonstrates accuracy and thoroughness. Looks for ways to improve and promote quality and monitors own work to ensure quality is met.Must demonstrate strong written and oral communication skills by conveying necessary information accurately, listening effectively and asking questions where clarification is needed.Must be able to work independently, prioritize work activities and use time efficiently.Must be able to maintain confidentiality.Must be able to demonstrate and promote a positive team-oriented environment.Must be able to stay focused and concentrate under normal or heavy distractions.Must be able to work well under pressure and/or stressful conditions.Must possess the ability to manage change, delays, or unexpected events appropriately.Demonstrates reliability and abides by the company attendance policy.Must maintain a professional and clean appearance at all times consistent with company standards.