TMF Health Quality Institute and C2C Innovative Solutions, Inc. are Equal Opportunity Employers (Minorities/Females/Vet/Disability)

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2017:52: Appeals Professional III ALJ
Position Code:2017:52
Team:QIC Part A East
Location:Remote - Anywhere USA
Job Responsibilities:

Position Purpose:
Performs highly complex (senior-level) work.  Provides dissatisfied beneficiaries and/or providers the opportunity to present documentation to demonstrate why an appeal should be allowed. Provides an independent second level determination based on the documentation, facts, laws, regulations, and guidelines.  Works under limited supervision, with moderate latitude for the use of initiative and independent judgment.

Essential Responsibilities:
• Responsible for significant or complex programs.
• Prepares for and participates in Administrative Law Judge hearings by providing oral support or written testimony as required.
• Oversees and reviews medical records/case file, writes a reconsideration 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 issues raised by the beneficiary, representative, and supplier have been addressed.  
• Provides a fair and impartial decision based on current evidence, regulations, policies, and procedures.
• Conducts research using online federal regulations, contract policy, standards of medical practice, contract manuals, coverage issues manuals, medical literature, and other related resources to complete an accurate and well-supported decision.
• Stays abreast of changes in regulations, medical and healthcare practices, policies and procedures. 
• Oversees and participates in case specific verbal discussions.
• Oversees and conducts reviews of appeals with multiple beneficiaries in one case.
• Oversees and coordinates responses to statistical analysis challenges with assistance from statisticians.
• Leads and/or participates in workgroups at the direction of management.
• Conducts quality reviews, as needed.
• Serves as a subject matter expert.
• Mentors and/or trains staff.
• Participates in special projects and performs other duties as assigned.

Job Qualifications:

Minimum Qualifications
• Associate's degree from an accredited college or university in healthcare or related discipline 
o 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.)

License, Certification or Registration
• Registered Nurse, Physical Therapist, Respiratory Therapist, or Occupational Therapist with an active license

• Five (5) years of 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 Part A

Knowledge, Skills and Abilities

Thorough knowledge of
• Research techniques
• Medical terminology
• Medicare program, including coverage and payment rules
• Medicare regulations, claims administration, and medical review processes
• Applicable laws, rules and regulations

Expert skill in
• Preparing correspondence/documents using correct spelling, grammar and punctuation; proofreading and reviewing documents for clarity and consistency
• Prioritizing and organizing work assignments
• Researching, analyzing and interpreting policies and state and federal laws and regulations
• The use of personal computers and applicable programs, applications and systems

Ability to
• Exercise logic and reasoning to define problems, establish facts and draw valid conclusions
• Make decisions that support business objectives and goals
• Identify and resolve problems or refer issues appropriately
• Communicate effectively verbally and in writing
• Adapt to the needs of internal and external customers
• Show integrity and ethical behavior; respect confidentiality, business ethics and organizational standards
• Assure compliance with regulatory, contractual and accreditation entries

Work Environment
Requires working in an office/cubicle environment; sitting, standing, walking, bending, twisting and/or reaching. Requires repetitive movement; ability to lift, carry, or move up to 25 lbs. when transporting work equipment or materials. May require ability to operate a motor vehicle; the ability to travel by motor vehicle and commercial airline.  May require overnight travel.