J29, Inc

Appeals Professional III (APIII) Overview: J29 is an employee centered healthcare management consulting company that specializes in processing, reviewing, and analyzing medical claims, records, disputes, and audits. Established in 2017, J29 prides itself on its employee centric culture and high employee retention rates that allow us to ensure that we are creating a working environment that prioritizes the employee experience. Our team brings corporate performance that stretches to various areas where we can provide our clinical, healthcare policy, and compliance expertise through our support to health and human service programs at the State, Federal, and Commercial levels. Position Purpose Performs complex (senior-level) work. Provides dissatisfied parties to a Medicare appeal the opportunity to present documentation to demonstrate why an appeal should be allowed. Provides an independent second level determination based on the documentation, facts, laws, regulations, and guidelines. Works under general supervision, with moderate latitude for the use of initiative and independent judgment. Essential Responsibilities - Reviews medical records/case file, writes a reconsideration decision letter that is clear, concise, and impartial and supports the determination made, and documents review. - Makes sound, independent decisions based on medical evidence in accordance with statutes, regulation, rulings, and policy. - Responds to and ensures that all appeal issues raised by the beneficiary/patient, representative, and provider/supplier have been addressed. - Provides a fair and impartial decision based on current evidence, regulations, policies, and procedures. - 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. - Stays abreast of changes in regulations, medical and healthcare practices, policies and procedures. - Participates in case specific verbal discussions. - Conducts reviews of appeals/disputes with multiple beneficiaries/services in one case. - Plans responses to statistical analysis challenges with assistance from statisticians. - Attends meetings and participates in workgroups at the direction of management. - Conducts quality reviews, as needed. - Serves as a subject matter expert. - Mentors and/or trains staff. - May conduct quality reviews and audits. - Participates in special projects and performs other duties as assigned. Minimum Qualifications Education - - 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. (Experience requirements may be satisfied by full-time experience or the prorated part-time equivalent.) Experience - - Three (3) years of medical dispute resolution or Medicare appeals, medical review, clinical, or related experience in a healthcare setting - Healthcare Professional with Nursing, Physical Therapy, Respiratory Therapy or Occupational Therapy experience - Demonstrated experience writing or making medical necessity decisions - Experience directly relevant to Medicare managed care appeals or utilization management activities, preferred - Resided in the United States for a minimum of three (3) years out of the last five (5) years? (Per Contract Requirement) Knowledge, Skills and Abilities Considerable knowledge of - Research techniques - Medical terminology - Medicare program, including coverage and payment rules - Medicare regulations, claims administration, and medical review processes - Applicable laws, rules and regulations Expert skill in - Preparing correspondence/documents using correct spelling, grammar and punctuation; proofreading and reviewing documents for clarity and consistency - Researching, analyzing and interpreting policies and state and federal laws and regulations Proficient skill in - Prioritizing and organizing work assignments - The use of personal computers and applicable programs, applications and systems Ability to - Multitask and meet deadlines - Exercise logic and reasoning to define problems, establish facts and draw valid conclusions - Make decisions that support business objectives and goals - Identify and resolve problems or refer issues appropriately - Communicate effectively verbally and in writing - Adapt to the needs of internal and external customers - Show integrity and ethical behavior; respect confidentiality, business ethics and organizational standards - Assures compliance with company policies, procedures, and guidelines including cybersecurity, regulatory, contractual and accreditation entities J29, Inc. is committed to hiring and retaining a diverse workforce. We are proud to be an Equal Opportunity/Affirmative Action Employer, making decisions without regard to race, color, religion, creed, sex, sexual orientation, gender identity, marital status, national origin, age, veteran status, disability, or any other protected class. J29, Inc. is a proud Veteran friendly employer.

Reconsideration Analyst I (RAI) Overview: J29 is an employee centered healthcare management consulting company that specializes in processing, reviewing, and analyzing medical claims, records, disputes, and audits. Established in 2017, J29 prides itself on its employee centric culture and high employee retention rates that allow us to ensure that we are creating a working environment that prioritizes the employee experience. Our team brings corporate performance that stretches to various areas where we can provide our clinical, healthcare policy, and compliance expertise through our support to health and human service programs at the State, Federal, and Commercial levels. Position Purpose: Performs routine appeals work. Serve as a support person for the reconsideration professionals and physician reviewers for second level reconsiderations resolutions. Works under close supervision, with minimal latitude for the use of initiative and independent judgement. Essential Responsibilities: - Coordinates the delivery of appeals case files resolution documents and reconsideration decisions from and to the external entities. - Build a reconsideration case file from evidence submitted or auto forwarded from Plans and analyzes each case to ensure it meets the requirements for a valid reconsideration as mandated by Centers for Medicare and Medicaid Services (CMS) or other customer entities. - Analyzes and makes decisions based on medical vs. non-medical case type, appeal/review categories, validity of appeal. - Inputs appropriate data regarding reconsiderations into the applicable required systems. - Responds to reconsideration from appellants/providers. - Routes or responds to telephonic and/or written inquiries from appellants/ about reconsiderations or about the reconsiderations process from appellants/or their legally designated representatives. - Identifies any suspected instances of fraud and/or abuse and immediately inform management of such issues. - Stays abreast of changes in regulations and practices, policies and procedures. - May submit requests for re-determination files and completed reconsideration and Administrative Law Judge (ALJ) decisions to relevant entities. - May support the processing of reopenings following receipt of ALJ remands. - Participates in special projects and performs other duties as assigned. Minimum Qualifications Education - High School Diploma or equivalent Experience - One (1) year of general office experience College education or technical training in administration, business, or related areas may be substituted for experience on a year per year basis. (Education requirements may be satisfied by full-time education or the prorated part-time equivalent.) - Experience directly relevant to Medicare managed care appeals or utilization management activities, preferred Knowledge, Skills and Abilities Some Knowledge of - Research techniques - Medicare appeals program - Applicable systems and applications - Applicable laws, rules and regulations Some Skill in - Preparing correspondence/documents using correct spelling, grammar and punctuation; proofreading and reviewing documents for clarity and consistency - Prioritizing and organizing work assignments - Researching, analyzing and interpreting policies and state and federal laws and regulations - The use of personal computers and applicable programs, applications and systems Ability to - Meet production and quality standards - Multitask and meet deadlines - Exercise logic and reasoning to define problems, establish facts and draw valid conclusions - Make decisions that support business objectives and goals - Identify and resolve problems or refer issues appropriately - Communicate effectively verbally and in writing - Adapt to the needs of internal and external customers - Show integrity and ethical behavior, respect for confidentiality, business ethics and organizational standards - Assures compliance with company policies, procedures, and guidelines including cybersecurity, regulatory, contractual and accreditation entities J29, Inc. is committed to hiring and retaining a diverse workforce. We are proud to be an Equal Opportunity/Affirmative Action Employer, making decisions without regard to race, color, religion, creed, sex, sexual orientation, gender identity, marital status, national origin, age, veteran status, disability, or any other protected class. J29, Inc. is a proud Veteran friendly employer.

*Candidate must have direct experience working on the Centers for Medicare & Medicaid Services Risk Adjustment Data Validation (CMS RADV) contract. *Day time availability is required due to meetings Position Summary The Coding Compliance Specialist is responsible for overseeing and evaluating assigned Risk Adjustment Data Validation (RADV) medical record review (MRR) work performed under the contract. This role ensures compliance with CMS RADV guidelines, coding standards, and risk adjustment policies while maintaining the highest quality and accuracy in medical record documentation. This is a part-time, remote position with flexible scheduling, ideal for experienced professionals seeking autonomy and work-life balance. Key Responsibilities - Ensure adherence to CMS RADV payment and risk adjustment policies. - Provide expert guidance on coding and documentation standards, including ICD-CM, HCC, and Risk Adjustment. - Review escalated Medicare RADV medical record cases and resolve complex issues. - Maintain quality assurance and compliance across all RADV review activities. - Collaborate with stakeholders to improve processes and ensure contractual obligations are met. - Conduct medical record, coding, and policy research. - Develop and deliver training programs related to RADV and coding compliance. - Perform medical record reviews involving PHI/PII, identify conflicting documentation, and provide coding clarifications. Experience Requirements - Prior experience working directly on the CMS RADV contract is required - Minimum 5 years of supervisory experience in medical record review, preferably RADV. - Proven expertise in reviewing escalated Medicare RADV medical record cases. - In-depth knowledge of RADV Medical Record Review (MRR) processes, ICD-CM coding standards, CMS RADV payment and risk adjustment policies, and documentation guidelines. Education & Certification - Medical Coding Certification from an accredited entity (e.g., AAPC, AHIMA). - RHIT, RHIA, CCS, CPC, CRC - Advanced knowledge of coding systems and compliance regulations. Skills & Competencies - Strong analytical and problem-solving skills. - Excellent communication and leadership abilities. - Detail-oriented with a commitment to accuracy and compliance. - Ability to manage multiple priorities and meet deadlines.