Reconsideration Analyst I
Remote
Full Time
Entry Level
Reconsideration Analyst I (RAI)
Overview:
J29 is an employee centered healthcare management consulting company that specializes in processing, reviewing, and analyzing medical claims, records, disputes, and audits. Established in 2017, J29 prides itself on its employee centric culture and high employee retention rates that allow us to ensure that we are creating a working environment that prioritizes the employee experience. Our team brings corporate performance that stretches to various areas where we can provide our clinical, healthcare policy, and compliance expertise through our support to health and human service programs at the State, Federal, and Commercial levels.
Position Purpose:
Performs routine appeals work. Serve as a support person for the reconsideration professionals and physician reviewers for second level reconsiderations resolutions. Works under close supervision, with minimal latitude for the use of initiative and independent judgement.
Essential Responsibilities:
Minimum Qualifications
Education
Experience
Knowledge, Skills and Abilities
Some Knowledge of
Some Skill in
Ability to
J29, Inc. is committed to hiring and retaining a diverse workforce. We are proud to be an Equal Opportunity/Affirmative Action Employer, making decisions without regard to race, color, religion, creed, sex, sexual orientation, gender identity, marital status, national origin, age, veteran status, disability, or any other protected class. J29, Inc. is a proud Veteran friendly employer.
Overview:
J29 is an employee centered healthcare management consulting company that specializes in processing, reviewing, and analyzing medical claims, records, disputes, and audits. Established in 2017, J29 prides itself on its employee centric culture and high employee retention rates that allow us to ensure that we are creating a working environment that prioritizes the employee experience. Our team brings corporate performance that stretches to various areas where we can provide our clinical, healthcare policy, and compliance expertise through our support to health and human service programs at the State, Federal, and Commercial levels.
Position Purpose:
Performs routine appeals work. Serve as a support person for the reconsideration professionals and physician reviewers for second level reconsiderations resolutions. Works under close supervision, with minimal latitude for the use of initiative and independent judgement.
Essential Responsibilities:
- Coordinates the delivery of appeals case files resolution documents and reconsideration decisions from and to the external entities.
- Build a reconsideration case file from evidence submitted or auto forwarded from Plans and analyzes each case to ensure it meets the requirements for a valid reconsideration as mandated by Centers for Medicare and Medicaid Services (CMS) or other customer entities.
- Analyzes and makes decisions based on medical vs. non-medical case type, appeal/review categories, validity of appeal.
- Inputs appropriate data regarding reconsiderations into the applicable required systems.
- Responds to reconsideration from appellants/providers.
- Routes or responds to telephonic and/or written inquiries from appellants/ about reconsiderations or about the reconsiderations process from appellants/or their legally designated representatives.
- Identifies any suspected instances of fraud and/or abuse and immediately inform management of such issues.
- Stays abreast of changes in regulations and practices, policies and procedures.
- May submit requests for re-determination files and completed reconsideration and Administrative Law Judge (ALJ) decisions to relevant entities.
- May support the processing of reopenings following receipt of ALJ remands.
- Participates in special projects and performs other duties as assigned.
Minimum Qualifications
Education
- High School Diploma or equivalent
Experience
- One (1) year 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.)
- Experience directly relevant to Medicare managed care appeals or utilization management activities, preferred
Knowledge, Skills and Abilities
Some Knowledge of
- Research techniques
- Medicare appeals program
- Applicable systems and applications
- Applicable laws, rules and regulations
Some 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
- The use of personal computers and applicable programs, applications and systems
Ability to
- Meet production and quality standards
- 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 for confidentiality, business ethics and organizational standards
- Assures compliance with company policies, procedures, and guidelines including cybersecurity, regulatory, contractual and accreditation entities
J29, Inc. is committed to hiring and retaining a diverse workforce. We are proud to be an Equal Opportunity/Affirmative Action Employer, making decisions without regard to race, color, religion, creed, sex, sexual orientation, gender identity, marital status, national origin, age, veteran status, disability, or any other protected class. J29, Inc. is a proud Veteran friendly employer.
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