Reconsideration Analyst III

at  TMF Health Quality Institute

Job Category: Administrative Support
Requisition Number: RECON001049
Posting Details
Posted: February 26, 2024
Full-Time
Locations
Remote, Anywhere USA
Job Details
Description

Education

• High School Diploma or equivalen

Experience

• Three (3) years 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.)
• Two (2) years high volume of customer calls, appeals, or billing
• Medicare, preferred
• Customer Service, preferre

POSITION PURPOSE:

Performs complex (journey-level) appeals work. Makes second level non-medical appeal decisions for beneficiaries, supplies, or providers. This may include cases dismissed by a contractor, Medicare Secondary Payer (MSP) recovery appeals, or Expedited appeals. Works under general supervision, with moderate latitude for the use of initiative and independent judgement.

Essential Responsibilities:

• Writes a reconsideration decision that is clear and supports the determination made.
• Ensures that all appeal issues raised by the beneficiary, representative, supplier, and/or provider have been addressed.
• Provides a fair and impartial decision based on current evidence, regulations, policies, and procedures.
• Ensures all documents are releasable and do not violate any Privacy Act provisions.
• Organizes documents by dates of service relevant to the charges, research denials and regulations used and ensure that any overpayment calculation is correct.
• Conducts research using online federal regulations, contract policy, standards of medical practice, contractor manuals, coverage manuals, and other related resources to complete an accurate and well-supported decision.
• May participate in Pre-decisional Appellant Discussions for the purpose of allowing the appellant to be heard and submit additional documentation.
• May provide subject matter expertise for Reconsideration Analysts regarding issues being appealed by dissatisfied beneficiaries or suppliers.

Minimum Qualifications

Education

• High School Diploma or equivalent

Experience

• Three (3) years 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.)
• Two (2) years high volume of customer calls, appeals, or billing
• Medicare, preferred
• Customer Service, preferred