Medicare Clinical Appeals Reviewer III

About the role

We are seeking a Medicare Clinical Appeals Reviewer III (Dispute Resolution Reviewer III) to support our federal client. The role involves evaluating complex Medicare appeals and dispute cases, reviewing clinical documentation, interpreting federal regulations, and issuing appeal determinations supported by medical evidence and policy.

Responsibilities

• Review the medical records/case file, write a reconsideration/dispute resolution decision that is clear, concise, and impartial, supports the determination made, and documents the review.
• Make fair, impartial, and independent decisions based on current medical evidence, statutes, regulations, rulings, policies, and procedures.
• Respond to and ensure that all appeal/dispute issues raised by the beneficiary/patient, representative, and provider/supplier have been addressed.
• Conduct research using online federal regulations, contract policy, standards of medical practice, contract manuals, coverage issues manuals, medical literature, and other related resources to make an accurate, well-supported decision.
• Stay abreast of changes in regulations, medical and healthcare practices, policies, and procedures.
• Participate in case-specific verbal discussions.
• Conduct reviews of appeals/disputes involving multiple beneficiaries/services in a single case.
• Plan responses to statistical analysis challenges with assistance from statisticians.
• Attend meetings and participate in workgroups at management's direction.
• Serve as a subject matter expert.
• Mentors and/or trains staff.
• Conduct quality reviews and audits, as needed.
• Participate in special projects and perform other duties as assigned.

Requirements

• Required Experience and Skills:
  • Must have 2-3 years of experience in medical dispute resolution, Medicare appeals, medical review, clinical review, or a related healthcare setting.
  • Must have Nursing, Physical Therapy, Respiratory Therapy or Occupational Therapy experience. Licensed candidates with closely related clinical or medical experience may be considered.
  • Demonstrated experience writing or making appeal or payment determinations.
  • Experience using Microsoft 365, including Excel and Word.
• Required Education and Training:
  • Must be an actively licensed healthcare professional with Nursing, Physical Therapy, Respiratory Therapy, Occupational Therapy, or closely related clinical experience.
• Physical Requirements:
  • Prolonged periods of sitting at a desk and working on a computer.
  • May need to lift 25 pounds occasionally.