The Redetermination Examiner conducts Medicare redetermination reviews and processes appeals in accordance with CMS guidelines. They are responsible for identifying claims processing deficiencies, maintaining accurate documentation, and providing educational referrals to ensure compliant outcomes.
The Medical Reviewer will evaluate complex claims, pre-authorization requests, and appeals to ensure medical necessity and accurate reimbursement. They will also provide clinical rationales for coverage determinations and support quality control initiatives.
The Appeals Support Specialist is responsible for managing and prioritizing workloads while accurately recording and indexing documentation in the OnBase system. They also coordinate with external stakeholders to order necessary documentation and communicate process trends to management.
The Appeals Support Specialist is responsible for managing and prioritizing workloads while accurately recording and indexing documentation in OnBase. They will also communicate with management regarding process trends and improvements.
The Redetermination Examiner conducts reviews of Medicare claims and responds to appeals in accordance with CMS regulations. They are responsible for identifying processing deficiencies, maintaining accurate documentation, and providing educational support to ensure compliant claim outcomes.
The Provider Enrollment Specialist is responsible for reviewing, researching, and processing medical provider enrollment applications to ensure accuracy and compliance. They also manage provider data in internal databases and communicate with various stakeholders to resolve discrepancies.
The role involves reviewing and responding to Medicare redetermination requests by analyzing medical documentation, coding, and policy guidelines. You will also collaborate with medical staff to determine claim outcomes and ensure accurate financial liability and decision letters.
Conduct pre- and post-payment medical reviews to ensure compliance with clinical criteria and guidelines. Assess medical necessity and reimbursement eligibility for complex claims, appeals, and fraud referrals.
The physician will conduct independent medical case reviews to assess quality of care and adherence to standards. They will also provide expert medical opinions and identify opportunities for improvement.
