Appeals Professional
New
Based in the United StatesFull-TimeMiddle
Salary not disclosed
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Job Details
- Experience
- Minimum of 3 years of experience
- Required Skills
- Analytical Skills
Requirements
- Minimum of 3 years of experience in Medicare appeals, medical review, clinical work, or healthcare-related dispute resolution.
- Strong knowledge of Medicare regulations, claims administration, coverage rules, and federal healthcare policies.
- Ability to research and interpret medical terminology, healthcare guidelines, and state/federal regulations accurately.
- Excellent written communication skills with strong grammar, clarity, and attention to detail in documentation.
- Strong analytical and critical thinking skills with the ability to draw logical conclusions from complex information.
- Proven ability to manage multiple priorities, meet deadlines, and work independently under general supervision.
- High level of integrity, professionalism, and commitment to confidentiality and ethical standards.
- Experience with Medicare managed care appeals is preferred.
- Associate’s degree or equivalent healthcare-related education/experience required.
Responsibilities
- Review complex appeal cases, including medical records and supporting documentation, to determine whether enrollment denials, suspensions, or revocations should be upheld or overturned.
- Issue clear, concise, and well-supported written determinations based on medical evidence, regulatory standards, and applicable policies.
- Conduct in-depth research using federal regulations, medical literature, contract manuals, and coverage guidelines to ensure accurate and compliant decisions.
- Ensure all issues raised by beneficiaries, providers, and representatives are fully addressed in each case review.
- Apply independent judgment to interpret statutes, policies, and clinical evidence in order to reach fair and impartial decisions.
- Participate in quality reviews, audits, and special projects to support continuous improvement of the appeals process.
- Stay current on evolving healthcare regulations, medical practices, and policy updates relevant to Medicare appeals.
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