[Hiring] Appeals Representative-Prior Authorization @GuideWell Source

Role Description

Team members are accountable for conducting a review of Medicare Part A or B claims on services questioned on appeal by a provider, facility, beneficiary, Centers for Medicaid and Medicare Services (CMS) or other interested parties using multiple computer applications. Incumbents render appeals decisions based on research of the initial claim processing activity, documented procedures and policies and information supplied with the appeal request and respond to the appeal in the form of an adjustment to payment, refund request for overpayment or a written response upholding the original processing of the service.

Essential Responsibilities

• Respond timely to Medicare inquiries that constitute an appeal or reopening of an initial claim determination: (90%)
  • Research electronic files and imaged records and/or access the appropriate external systems such as Multi-Carrier System (MCS), Fiscal Intermediary Standard System (FISS), Medicare Appeals System (MAS) as well as Microsoft Windows applications including Excel files and Word documents.
  • Read and interpret processing guidelines, determine the accuracy of the original claim determination and take the necessary actions to finalize the case file. Perform claim correction activity of the initial claim determination when an additional payment or a reduction in payment correction is necessary.
  • Review additional documentation (e.g., office notes, test results, medical records, etc.) submitted with the request to determine if this information should be forwarded to a clinician for additional consideration or utilize the additional documentation to make the redetermination decision.
• Resolve adjustment claims which suspend due to system edits/audits or have been returned to the department from entities conducting subsequent levels of review. (10%)
• Perform other duties as the supervisor may, from time to time, deem necessary.

Qualifications

• High School diploma or GED
• 2 years' experience utilizing research skills in reading and interpreting information
• PC experience in Microsoft Windows or similar environment -- includes Word, Excel, PowerPoint, etc.
• Demonstrated verbal and written communication skills
• Demonstrated customer service skills
• Demonstrated ability to make independent decisions relating to claims processing accuracy relying on various online reference tools

Preferred Qualifications

• Sound research and decision-making skills to respond to the inquiry in accordance with Medicare procedures and guidelines
• Demonstrated knowledge of Medicare policies and benefits, internal processing instructions, as well as medical terminology
• Medicare claims processing experience or a medical background
• Knowledge of Medicare processing systems

Requirements

• The Federal Government and the Centers for Medicare & Medicaid Services (CMS) may require applicants to have lived in the United States for a minimum of three (3) years out of the last five (5) years to be employed with the Company. These years of residence do not have to be consecutive.
• Background Investigation: If you are selected for this position, you must undergo a pre-employment Background Investigation, Drug Screen, and Identity Proofing documentation must be cleared prior to hire. Most positions are subject to additional Identity Proofing, Fingerprinting and additional Background Investigation screening conducted by the Federal Government to be granted Enterprise User Administration (EUA) system logical access after you begin your employment. Your continued employment is contingent upon the outcome of the complete additional screening criteria required for the position which must find that you meet the applicable government customer's requirements (e.g., suitable for access to CMS information and information systems), as well as any additional investigation which may be required throughout your employment. If you are found not suitable, your employment may be subject to corrective action, up to and including immediate termination of employment.
• Identity Documentation: You must have access to a current and unrestricted REAL ID, U.S. Passport, U.S. Passport Card, Foreign Passport, or U.S. Permanent Residency Documents. Note: Employment Authorization Cards (EAD) are not a substitute for Visas or U.S. Permanent Resident Cards.

Benefits

• Medical, dental, vision, life and supplemental insurance plans effective the first day of the month following date of hire
• Short- and long-term disability benefits
• 401(k) plan with company match and immediate vesting
• Free telehealth benefits
• Free gym memberships
• Employee Incentive Plan
• Employee Assistance Program
• Rewards and Recognition Programs
• Paid Time Off and Paid Sick Leave

Company Description

We are an Equal Opportunity/Protected Veteran/Disabled Employer.

This opportunity is open to remote work in the following approved states: AL, FL, GA, ID, IN, IO, KS, LA, MS, NE, NC, ND, OH, PA, SC, TN, TX, UT, WV, WI, WY. Specific counties and cities within these states may require additional approval. In FL and PA in-office and hybrid work may also be available.