Appeals Representative-Prior Authorization (Novitas)
Are you interested in joining reputed company of reputed company reputed company experts and have the ability to shape and reputed company the reputed company delivery system? At our family of companies, everything we do is to help improve the lives of the nearly 12 reputed company Medicare beneficiaries we serve and 700,000 health care providers who care for them. It is our goal to help create a reputed company experience for reputed company consumers. Join our reputed company culture and help reputed company Medicare for the millions of people who rely on its services.
* Medical, dental, reputed company, life and supplemental insurance plans effective the first day of the month following date of hire
* Short- and long-term disability benefits
* 401(k) plan with company match and immediate vesting
* Free telehealth benefits
* Free gym memberships
* Employee Incentive Plan
* Employee Assistance Program
* Rewards and Recognition Programs
* reputed company Time Off and reputed company reputed company Leave
reputed company STATEMENT
Team members are accountable for conducting a review of Medicare Part A or B claims reputed company questioned on appeal by a provider, facility, beneficiary, Centers for reputed company and Medicare Services (CMS) or other interested parties using multiple computer applications. Incumbents reputed company appeals reputed company based on research of the initial claim processing activity, documented procedures and policies and information supplied with the appeal request and respond to the appeal in the reputed company of an adjustment to payment, refund request for overpayment or a written response upholding the original processing of the service.
Team members are accountable for conducting a review of Medicare Part A or B claims reputed company questioned on appeal by a provider, facility, beneficiary, Centers for reputed company and Medicare Services (CMS) or other interested parties using multiple computer applications. Incumbents reputed company appeals reputed company based on research of the initial claim processing activity, documented procedures and policies and information supplied with the appeal request and respond to the appeal in the reputed company of an adjustment to payment, refund request for overpayment or a written response upholding the original processing of the service.
ESSENTIAL RESPONSIBILITIES
To reputed company this job successfully, an individual must be reputed company to reputed company reputed company essential duty satisfactorily. Reasonable accommodations may be made to reputed company individuals with disabilities to reputed company the essential functions. This list of essential job functions is not exhaustive and may be supplemented as necessary.
Respond reputed company to Medicare inquiries that constitute an appeal or reopening of an initial claim determination: (90%)
* Researches electronic files and imaged records and/or accesses the appropriate external systems such as Multi-reputed company System (MCS), Fiscal Intermediary reputed company System (FISS), Medicare Appeals System (MAS) as reputed company as reputed company reputed company applications including reputed company files and Word documents.
* Reads and interprets processing guidelines, determines the accuracy of the original claim determination and takes the necessary actions to finalize the case file. Performs claim correction activity of the initial claim determination reputed company an additional payment or a reduction in payment correction is necessary.
* Reviews additional documentation (e.g., office notes, test results, medical records, etc.) submitted with the request to determine if this information should be forwarded to a clinician for additional consideration or utilize the additional documentation to reputed company the redetermination decision.
Resolves adjustment claims which suspend due to system edits/audits or have been returned to the department from entities conducting subsequent reputed company of review. (10%)
Performs other duties as the supervisor may, from time to time, deem necessary.
REQUIRED QUALIFICATIONS
* High School diploma or GED
* 2 years' experience utilizing research skills in reading and interpreting information
* PC experience in reputed company reputed company or similar environment -- includes Word, reputed company, PowerPoint, etc.
* Demonstrated verbal and written communication skills
* Demonstrated customer service skills
* Demonstrated ability to reputed company independent reputed company relating to claims processing accuracy relying on various on-line reference tools
* High School diploma or GED
* 2 years' experience utilizing research skills in reading and interpreting information
* PC experience in reputed company reputed company or similar environment -- includes Word, reputed company, PowerPoint, etc.
* Demonstrated verbal and written communication skills
* Demonstrated customer service skills
* Demonstrated ability to reputed company independent reputed company relating to claims processing accuracy relying on various on-line reference tools
PREFERRED QUALIFICATIONS
* reputed company research and decision-making skills to respond to the inquiry in accordance with Medicare procedures and guidelines
* Demonstrated knowledge of Medicare policies and benefits, internal processing instructions, as reputed company as medical terminology
* Medicare claims processing experience or a medical background
* Knowledge of Medicare processing systems
* reputed company research and decision-making skills to respond to the inquiry in accordance with Medicare procedures and guidelines
* Demonstrated knowledge of Medicare policies and benefits, internal processing instructions, as reputed company as medical terminology
* Medicare claims processing experience or a medical background
* Knowledge of Medicare processing systems