Redetermination Examiner

• Position is Eligible for Remote / Work from Home Opportunity Department: Part B AppealsJob Grade: N12As a condition of employment physical work location must be in one of the 50 states or the District of Columbia.*

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Job TitleRedeterminations ExaminerJob SummaryThe Redeterminations Examiner is responsible for examining incoming Medicare Redetermination appeals through a review of documentation to make appeal determinations. This position determines if adjustments within standard systems are in accordance with established guidelines and policies and responds to Medicare appellants ensuring quality administration of Centers for Medicare and Medicaid Services (CMS) regulations and continuous, proactive customer satisfaction.

Essential Functions Key Duties/Responsibilities/Accountabilities

• Conducts redetermination reviews per Medicare rules and regulations

• Responds to incoming appeals from Medicare appellants in a professional, timely, and accurate manner. Including letter writing, proofreading with attention to detail following current guidelines.

• Researches and identifies claims processing deficiencies and initiates corrective response

• Evaluates all documentation and history needed to determine if it meets outlined policy criteria to ensure accurate and compliant processing in accordance with CMS guidelines.

• Submits educational referrals as necessary to decrease redeterminations and allow claims to pay at the lowest level of appeal

• Assists in writing and updating processing guidelines

• Identifies internal/external education and/or training needs, communicates findings, and assists in training if necessary

• Communicates information to appropriate internal and external parties in a timely manner

• Problem solves and researches effectively

• Process overpayment appeals as needed

• Maintain up-to-date knowledge of working systems, processing instructions, and other relevant resourrces to ensure efficient and accurate appeal processing.

• Maintains knowledge of CMS and Joint Operating Agreement (JOA) requirements

Non-Essential Duties and Functions

• Other duties as assigned

• May facilitate trainings and/or meetings

• May provide back up support to the Process Team

Minimum Qualifications

• High School diploma or GED

• 6 months' work related experience

• General PC knowledge

• Prioritization skills

• Strong communication skills

• Strong analytical skills

• Ability to adapt to changes

Preferred QualificationsAbove requirements and the following:

• 1-year redetermination processing experience

• Knowledge of medical terminology, Claims Processing Timelines (CPT), Healthcare Common Procedure Coding System (HCPCS) and ICD coding

Environment and Cognitive/Physical Demands

• Office Environment

• Ability to read, hear, speak, keyboard, reason, communicate effectively and problem solve

• Requires prolonged sitting and telephone use

• Requires the use of office equipment such as computer terminals, telephones, copiers and printers

• Infrequent lifting to 15 pounds

• Infrequent stooping

Segregation of DutiesEvery employee is responsible to perform their duties and responsibilities in accordance with Noridian values, policies and procedures, including but not limited to: Segregation of Duties Principles, HIPAA, Security and Privacy, CMS requirements, the Noridian Compliance Program and any other applicable laws, rules and regulations.

Statement of Other DutiesThis document describes the essential functions, requirements, and responsibilities of this job, and is not intended to be a complete list of all tasks and functions. Employees may be requested to perform job related tas...