Redetermination Examiner (Medicare, DME) (6 Month Temp)

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.
• Processes overpayment appeals as needed.
• Maintain up-to-date knowledge of working systems, processing instructions, and other relevant resources to ensure efficient and accurate appeal processing.
• Maintains knowledge of CMS and Joint Operating Agreement (JOA) requirements

Minimum Qualifications:

• High School Diploma or GED
• 6 months’ work-related experience

Proficiencies:

• General PC knowledge
• Strong prioritization, analytical and communication skills
• Ability to adapt to changes