Job Title: Medical Claims & Appeals Specialist (Dispute Resolution Reviewer)

Target Candidate Background: Medical Billing/Medical Claims experience. Must be able to read and EOB. Will be getting cases ready for arbitration so must have experience with billing, claims, coding.

Training hours: 9am-4pm EST

Work hours: Must be able to work 9am-3pm but can choose your start and end time before 9am or after 3pm to work a full 40 hours, Monday-Friday.

Location: Remote (can sit anywhere but ideally in CST or EST timezones)

Pay: $21-25/hr

Position Purpose:
Performs complex (journey-level) work. Provides dissatisfied beneficiaries and/or providers the opportunity to present documentation or evidence to demonstrate why an appeal or rebuttal for an enrollment denial, revocation, or suspension should be allowed. Provides an independent second level determination based on the documentation, facts, laws, regulations, and guidelines. Works under general supervision, with moderate latitude for the use of initiative and independent judgment.

Essential Responsibilities:

• Reviews medical records/case file, writes a decision 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 issues raised by the beneficiary, representative, supplier, and provider 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 special projects and performs other duties as assigned.

Minimum Qualifications

• High School Diploma required 
• Additional experience in Medicare appeals, medical review, clinical, or other related experience in a healthcare setting

Experience

• One (1) year of Medicare appeals, medical review, clinical, healthcare regulatory interpretation/application, healthcare compliance or related experience in a healthcare setting

Knowledge, Skills and Abilities
• Research techniques
• Medical terminology
• Medicare program, including coverage and payment rules
• Medicare regulations, claims administration, and medical review processes
Proficient skill in
• Preparing correspondence/documents using correct spelling, grammar and punctuation; proofreading and reviewing documents for clarity and consistency
• Prioritizing and organizing work assignments
• Researching, analyzing and interpreting policies and state and federal laws and regulations
Ability to
• Multitask and meet deadlines
• Exercise logic and reasoning to define problems, establish facts and draw valid conclusions
• Make decisions that support business objectives and goals
• Identify and resolve problems or refer issues appropriately
• Communicate effectively verbally and in writing
• Adapt to the needs of internal and external customers
• Show integrity and ethical behavior; respect confidentiality, business ethics and organizational standards
• Assures compliance with company policies, procedures, and guidelines including cybersecurity, regulatory, contractual and accreditation entities

^*We will consider for employment all qualified Applicants, including those with criminal histories, in a manner consistent with the requirements of applicable federal, state, and local laws, including the City of Los Angeles' Fair Chance Initiative for Hiring Ordinance (FCIHO), Los Angeles Fair Chance Ordinance for Employers (ULAC), The San Francisco Fair Chance Ordinance (FCO), and the California Fair Chance Act (CFCA).

^*As a job position within our Insurance division, a successful completion of a background check may be required as a condition of employment. This requirement is directly related to essential job functions including but not limited to: accessing medical and confidential records, verifying financial information, and working within departments that care for vulnerable populations, such as, minors, elderly and those with physical or mental disabilities. Due to these job duties, this position has a significant impact on the business operations and reputation, as well as the safety and well-being of individuals who may be cared for as part of the job position or who may interact with staff or clients