Appeals Professional IV (Weekend Work)

Please make sure your application is complete, including your education, employment history, and any other applicable sections. Initial screening is based on the minimum requirements as defined in the job posting, such as education, experience, licenses, and certifications.  Your experience should also address the knowledge, skills and abilities needed for the role. Incomplete applications will not be considered.

*This is a remote, work from home position within the United States*

"A sign-on bonus may be available for candidates with relevant experience and immediate availability"

Position Purpose

 Provides dissatisfied patient/beneficiaries and/or providers the opportunity to present documentation to demonstrate why an appeal/dispute should be allowed. Provides an independent second level determination/dispute resolution based on the documentation, facts, laws, regulations, and guidelines.  

Essential Responsibilities

• Responsible for significant or complex programs.

• Participates in formal pre-decisional appellant/requestor/provider discussions for the purpose of allowing the appellant/requestor/provider to be heard and submit additional documentation; or, engages the parties in other types of communication in order to obtain information and a more complete understanding of the appeal/dispute issues.
• Oversees and reviews medical records/case file, writes a reconsideration/dispute resolution decision 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.
• Oversees, responds to and ensures that all appeal/dispute issues raised by the beneficiary/patient, representative, and provider/supplier have been addressed.

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

• Five (5) years of medical dispute resolution or Medicare appeals, medical review, clinical, or related experience in a healthcare setting
• Healthcare Professional with demonstrated experience writing or making medical necessity decisions
• Nursing, Physical Therapy, Respiratory Therapy or Occupational Therapy experience

• Medicare Fee for Service or Managed Care

Benefits

C2C offers an excellent benefits package, including:

• Medical, dental, vision, life, accidental death and dismemberment, and short and long-term disability insurance
• Section 125 plan
• 401K
• Competitive salary
• License/credentials reimbursement
• Tuition Reimbursement

EOE Vet/Disability