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Medicare Appeals Specialist in Philadelphia, PA at Integrated Resources, Inc

Date Posted: 1/24/2019

Job Snapshot

Job Description

Medicare Appeals Specialist

The primary purpose of the job is to:
The Appeals Specialist reports to the Director of Appeals and Grievances and will coordinate and perform all appeal related duties in a Medicare Advantage Dual Special Needs Plan and Medicare-Medicaid Plans. These appeals will include requests for decisions regarding denials of medical services as well as Part D drugs. The Appeals Specialist will be responsible for a) analyzing and responding appropriately to appeals from members, member representatives and providers regarding denials for services and denials of payment via oral and written communication; b) researching and applying pertinent Medicare and Medicaid regulations to determine the outcome of the appeal; c) provide oversight and assistance to Medical Management staff with resolution of appeal by interpreting Medicare and Medicaid regulations; d) reviewing documentation to ensure that all aspects of the appeal have been addressed properly and accurately; e) prepare case files for submission to Independent Review Entity, which also include writing a position paper on behalf of the plan to support appeal resolution; f) generate and analyze reporting to determine trends in appeal requests and decisions and g) performs other tasks as assigned.

Bachelor's Degree
Working knowledge of Medicare Advantage, Original Medicare and Medicaid appeal regulations.
Local Coverage Determinations, National Coverage Determinations
Working knowledge of CPT, HCPCS, ICD-9 definitions
Must be detailed-oriented and proficient at time management.

Strong organization and time management skills with the ability to prioritize workloads. Required to work independently AND as part of a team.
Must have excellent written and verbal communication skills.
2-3 years of Medicare Appeals Resolution Experience