Responsibilities:
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Reviews medical records/case file, writes a reconsideration decision letter that is clear, concise, and impartial and supports the determination made, and documents review.
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Makes sound, independent decisions based on medical evidence in accordance with statutes, regulation, rulings, and policy.
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Responds to and ensures that all appeal issues raised by the beneficiary/patient, representative, and provider/supplier have been addressed.
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Provides a fair and impartial decision based on current evidence, regulations, policies, and procedures.
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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.
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Stays abreast of changes in regulations, medical and healthcare practices, policies and procedures.
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Participates in case specific verbal discussions.
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Conducts reviews of appeals/disputes with multiple beneficiaries/services in one case.
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Plans responses to statistical analysis challenges with assistance from statisticians.
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Attends meetings and participates in workgroups at the direction of management.
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Conducts quality reviews, as needed.
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Serves as a subject matter expert.
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Mentors and/or trains staff.
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May conduct quality reviews and audits.
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Participates in special projects and performs other duties as assigned.
Experience Must:
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Three (3) years of medical dispute resolution or Medicare appeals, medical review, clinical, or related experience in a healthcare setting
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Licensed nurse with 3 or more years of experience conducting appeals
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Healthcare Professional with Nursing, Physical Therapy, Respiratory Therapy or Occupational Therapy experience
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Demonstrated experience writing or making medical necessity decisions
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Experience directly relevant to Medicare managed care appeals or utilization management activities, preferred
Minimum Education Qualifications:
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.
"C-HIT is an EOE, including disability and veterans."
