Federal Hearings And Appeals

Role Description - Provide timely review and determination of medical claims, including prior authorization, appeals, and/or any other type of medical claims. - Analyze medical records related to the case file. - Review and interpret Local Coverage Determination (LCD), National Coverage Determination (NCD) policies, and other federal regulations. - Apply appropriate regulatory citations, including health plan policies, NCD/LCDs, and/or other regulations to each claim as it relates to the item or issue. - Formulate a narrative decision citing relevant regulatory back-up documentation contained within the medical record. - Adjudicate claim based on the regulations and documentation contained within the medical record. - Attend FHAS and/or client Lunch & Learn sessions and/or general training sessions on site as needed. - Complete IRR surveys in a timely fashion as required by the prime contractor. - Maintain a 97% or higher quality score. Qualifications - Certified Professional Coder (CPC) or Certified Coding Specialist (CCS) certification through the American Academy of Professional Coders (AAPC) or AHIMA preferred. - Must possess a current, unrestricted State license as a Registered Nurse (RN), Licensed Practical Nurse (LPN), Registered Pharmacist, Occupational Therapist, Physical Therapist, Speech Therapist, or equivalent medical degree as required by contract(s). - 1+ years clinical experience required; coding, utilization, and/or medical chart review preferred. - Professional Coding Certification preferred. - Detailed knowledge of Medicare regulations and guidelines, policies, and payor reimbursements preferred. - Knowledge of CPT, HCPCS, ICD-10 codes and coding guidelines. - Ability to identify Medicare billing and payment irregularities. - Must be able to support review findings by utilizing exceptional analytical, written and oral communication skills. - Ethical, self-motivated and results oriented team player. - Strong analytical, verbal and written communication skills. - Outstanding people skills and ability to effectively review findings/results with management. - Must be proficient with PC and related software programs. - Excellent organizational skills. - Must be a team player. - Limited travel may be required. Requirements - Must be able to remain in the stationary position 95% of the time. - Constantly operate a computer and other office equipment such as telephone. - Regular & predictable attendance is essential for this position. - Remote but need to be local to 18702. - RN preferred but LPN will be considered.