** REMOTE ** Determinations Specialist (32573)

Job DetailsJob Location: Lawrenceville, GA 30043Position Type: Full TimeSalary Range: $22.00 - $26.00 HourlyAre you a Medicare Set-Aside expert who enjoys analyzing complex cases, solving problems, and making a meaningful impact? ExamWorks is seeking a highly skilled Determinations Specialist to join our team and play a critical role in advocating for accurate Medicare Set-Aside (MSA) recommendations and ensuring compliance with CMS guidelines. In this position, you'll leverage your clinical knowledge, analytical expertise, and critical thinking skills to evaluate CMS determination letters, identify discrepancies, conduct research, and support successful MSA outcomes for our clients. If you're passionate about navigating complex regulatory requirements and collaborating with clients to achieve the best possible results, we'd love to hear from you. Schedule: Monday-Friday, 8:00 AM-5:00 PM Required Qualifications Current MSCC (Medicare Set-Aside Certified Consultant) certification Strong knowledge of the WCMSA Reference Guide and CMS Medicare coverage guidelines Exceptional analytical, research, and problem-solving skills Strong written and verbal communication abilities Medicare Set-aside Certified Consultant (MSCC) Medicare Set-aside (MSA) Centers for Medicare & Medicaid Services (CMS) Workers' Compensation Review Contractor (WCRC) MSP Compliance Medicare Secondary Payer (MSP)   Qualifications  What You'll Do As a Determinations Specialist, you will: Review CMS determination letters and evaluate cases with and without disagreement regarding MSA recommendations. Identify, analyze, and communicate discrepancies between ECS and CMS recommendations. Conduct comprehensive research and gather supporting clinical and regulatory documentation to substantiate ECS MSA recommendations. Assess CMS findings and determine whether a case warrants reconsideration. Partner with clients to explain recommendations, provide supporting rationale, and determine next steps. Utilize your expertise in Medicare coverage policies and the WCMSA Reference Guide to support case evaluations and decision-making. Analyze and defend ECS recommendations, including complex prescription drug allocations. Build compelling, well-documented submissions and supporting materials for presentation to CMS. Maintain accurate and timely documentation within Galileo and other company systems. Ensure compliance with client protocols, departmental procedures, HIPAA requirements, and all applicable regulations. Contribute to a collaborative team environment while supporting additional projects and initiatives as assigned. Why Join ExamWorks? At ExamWorks, you'll work alongside industry experts in a highly specialized field where your knowledge and expertise directly influence outcomes for clients. This role offers the opportunity to tackle challenging cases, deepen your regulatory expertise, and contribute to a team dedicated to excellence, accuracy, and continuous improvement. If you're an experienced MSCC professional looking for a role that values critical thinking, attention to detail, and subject matter expertise, we encourage you to apply today.   QUALIFICATIONS Previous Customer Service experience required. Minimum 12 months production environment experience or related experience preferred. Adequate knowledge of 3rd party/COB (Coordination of Benefits) / insurance verification / medical billing (ICD-9/CPT) experience preferred. Competency in mathematics, business terminology, clerical skills and time management. Must possess complete knowledge of general computers, fax, copier, scanner, and telephone. Must be knowledgeable of multiple software programs, including but not limited to Microsoft Word, Outlook, Excel, Adobe and the Internet. Must have a full understanding of HIPAA regulations and compliance. Ability to follow instructions and respond to managements’ directions accurately. Demonstrates accuracy and thoroughness. Looks for ways to improve and promote quality and monitors own work to ensure quality is met. Must demonstrate strong written and oral communication skills by conveying necessary information accurately, listening effectively and asking questions where clarification is needed. Must be able to work independently, prioritize work activities and use time efficiently. Must be able to maintain confidentiality. Must be able to demonstrate and promote a positive team-oriented environment. Must be able to stay focused and concentrate under normal or heavy distractions. Must be able to work well under pressure and/or stressful conditions. Must possess the ability to manage change, delays, or unexpected events appropriately. ExamWorks, LLC is an Equal Opportunity Employer and affords equal opportunity to all qualified applicants for all positions without regard to protected veteran status, qualified individuals with disabilities and all individuals without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age or any other status protected under local, state or federal laws.   Equal Opportunity Employer - Minorities/Females/Disabled/Veterans   #LI-MB1