Redetermination Examiner

Mission: The mission of BAC Enterprises is to provide persons with disabilities innovative services and opportunities to achieve personal success.

About the role

Under general supervision, examines incoming Medicare redetermination appeals by reviewing documentation, claim history, and applicable guidelines to make appeal determinations. Determines whether adjustments within standard systems are appropriate and responds to Medicare appellants while supporting accurate administration of CMS regulations and proactive customer satisfaction.

Responsibilities

• Conducts redetermination reviews in accordance with Medicare rules, regulations, and established guidelines.
• Responds to incoming appeals from Medicare appellants in a professional, timely, and accurate manner.
• Prepares, proofreads, and issues correspondence in accordance with current guidelines.
• Researches and identifies claims processing deficiencies and initiates appropriate corrective responses.
• Evaluates documentation, claim history, and policy criteria to support accurate and compliant appeal processing.
• Submits educational referrals as necessary to reduce redeterminations and support claims resolution at the lowest appropriate level of appeal.
• Assists with writing, reviewing, and updating processing guidelines.
• Identifies internal or external education and training needs, communicates findings, and assists with training as necessary.
• Communicates information to appropriate internal and external parties in a timely manner.
• Researches issues, analyzes information, and problem-solves effectively.
• Processes overpayment appeals as assigned.
• Maintains current knowledge of working systems, processing instructions, CMS requirements, Joint Operating Agreement requirements, and other relevant resources.
• Performs other duties and special projects as assigned.

Supervisory Responsibility

This position has no formal supervisory responsibility. May coordinate work activities, provide workload guidance, and support training or reporting activities as assigned.

Requirements

• High School Diploma or equivalent.
• Minimum of six (6) months of work-related experience.
• Must successfully pass all required pre-employment screenings, including a drug screening.
• Ability to obtain and maintain any required access approvals, credentials, or background clearances applicable to the assigned contract or work location.

Preferred Qualifications

• Experience with Medicare claims, appeals processing, healthcare administration, customer service, or records review.

Skills

• General PC knowledge and ability to work within standard business systems.
• Strong prioritization, analytical, and communication skills.
• Ability to adapt to changes in guidelines, systems, workloads, and business needs.
• Ability to review documentation and apply policies, procedures, and guidelines accurately.
• Ability to prepare clear, accurate, and professional written correspondence.
• Ability to research issues, identify deficiencies, and recommend corrective responses.
• Ability to maintain confidentiality and handle sensitive information appropriately.
• Strong attention to detail and commitment to quality and compliance.

Physical Requirements

Employees must be able to perform the essential physical requirements of the position, with or without reasonable accommodation, for extended periods of time. Duties may include:

• Sitting or standing for extended periods while performing computer-based work.
• Using hands and fingers for keyboarding, data entry, document review, and other office tasks.
• Viewing computer screens, reports, electronic records, and other written materials for extended periods.
• Communicating verbally and in writing with supervisors, coworkers, customers, and other stakeholders.
• Lifting, carrying, or moving standard office materials and equipment weighing up to 25 pounds.

Safety and Environmental Requirements

Work is performed primarily in an office or remote office environment using standard office equipment and computer systems. Employees may experience routine office noise, interruptions, deadlines, and extended periods of computer-based work. Employees are required to comply with company safety policies, information security requirements, confidentiality standards, and established procedures.

Sensory Requirements

Requires visual acuity, manual dexterity, concentration, attention to detail, and the ability to read, review, enter, and verify information accurately using computer systems.

Schedule

• Full Time Remote
• Candidates must reside within 55 miles of Rockledge, Florida.
• Monday-Friday (shift times between 8 am and 8 pm).

Pay

$17.77/hr.

Benefits

• Free medical, dental, and vision insurance for employees, and a buy-up option is available.
• Medical opt-out plan is available for qualified employees.
• Paid holidays and sick time.
• Paid vacation is available after one year of employment, based on the number of hours worked.
• Full-time employees are eligible to participate in the 401k plan on the first of the month following their date of hire.
• Additional Supplemental benefits are available, including Accident, Critical Illness, Short Term Disability, and Hospital.
• Employee Assistance Program.