Appeals Professional III
Remote
Full Time
Mid Level
Appeals Professional III (APIII)
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 complex (senior-level) work. Provides dissatisfied parties to a Medicare appeal the opportunity to present documentation to demonstrate why an appeal 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
Education
Knowledge, Skills and Abilities
Considerable knowledge of
Expert skill in
Proficient 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 complex (senior-level) work. Provides dissatisfied parties to a Medicare appeal the opportunity to present documentation to demonstrate why an appeal 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 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.
Education
- 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. (Experience requirements may be satisfied by full-time experience or the prorated part-time equivalent.)
- Three (3) years of medical dispute resolution or Medicare appeals, medical review, clinical, or related experience in a healthcare setting
- 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
- Resided in the United States for a minimum of three (3) years out of the last five (5) years? (Per Contract Requirement)
Knowledge, Skills and Abilities
Considerable knowledge of
- Research techniques
- Medical terminology
- Medicare program, including coverage and payment rules
- Medicare regulations, claims administration, and medical review processes
- Applicable laws, rules and regulations
Expert skill in
- Preparing correspondence/documents using correct spelling, grammar and punctuation; proofreading and reviewing documents for clarity and consistency
- Researching, analyzing and interpreting policies and state and federal laws and regulations
Proficient skill in
- Prioritizing and organizing work assignments
- The use of personal computers and applicable programs, applications and systems
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
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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