Medicare Appeals Specialist

Overview

Under the direction of the Supervisor, the Medicare Appeals Specialist receives, investigates, and responds to formal Medicare appeals. The Medicare Appeals Specialist is responsible for evaluating clinical criteria within medical records and associated documentation to validate, justify and write arguments to appeal Medicare claim denials. The Medicare Appeals Specialist maintains up to date and accurate knowledge of the product’s National Coverage Determination, Local Coverage Determination, related Policy Articles and the Medicare Program Integrity Manual.

Responsibilities

Responsible for performing end to end tasks for Medicare appeals such as writing, submitting, and reviewing outcomes for Redeterminations, Reconsiderations, Administrative Law Judge hearings, and Medicare Appeals Council decisions.Develop well-written Medicare appeals that support medical necessity and address payer objections by leveraging regulatory guidelines and available published research to support rebuttals.Collaborate with stakeholders such as patients, clinicians, payers, and field representatives to overcome payer challenges.Overcome objections that prevent payment of the claim, maximize reimbursement, and enhance patient access to our products. Triage incoming communications on appeal activity and maintain appropriate records of submissions and correspondence.Review denied and approved appeals and make recommendations on the best approach to address future denials.Other duties and requests as assignedMaintain compliance with all appropriate regulatory requirements including HIPAA

Qualifications

Required

Bachelor’s degree or equivalent experience2+ years’ experience in persuasive writing, claim appeals, or navigating legal or compliance programs2+ years’ experience in medical device industry, health insurance or related field

Preferred

Previous experience assessing payer coverage criteriaPrevious experience working with Medicare, Medicaid, or private payersClinical, regulatory, legal, or compliance background or experience in policy workClinical training, background, or education

Below is the starting salary range for this position, although offers may differ based on the candidate's location, job-specific knowledge, skills and experience.

$23.41 - $30.69 / HR

Additional Benefits

non-exempt - Our total compensation package includes medical, dental and vision benefits, retirement benefits, employee stock purchase plan, paid time off, parental leave, family medical leave, volunteer time off and additional leave programs, life insurance, disability coverage, and other life and work wellness benefits and discounts. Benefits may be subject to generally applicable eligibility, waiting period, contributions, and other requirements and conditions.