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Redeterminations Examiner I - 300157

Employer
Noridian Healthcare Solutions
Location
Grand Forks, ND
Salary
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Industry
Professional Services
Role
Other
Job Type
Long-Term
Hours
Full Time
Job Summary

The Redetermination Examiner is responsible for examining incoming Medicare Redetermination appeals through a review of documentation to make appeal determinations. This position determines if adjustments within standard systems are in accordance with established guidelines and policies and responds to Medicare appellants ensuring quality administration of CMS (Centers for Medicare and Medicaid Services) regulations and continuous, proactive customer satisfaction.

Key Performance Indicators
  • Effectively reviews redeterminations and possesses strong communication skills
  • Ability to identify processing deficiencies and initiate a corrective response
  • Knowledge of CMS and Joint Operating Agreement (JOA) requirements


Essential Functions

FLSA Category: Non-Exempt

Key Duties/Responsibilities/Accountabilities
  • Ensures all aspects of redeterminations are complete and accurate.
  • Responds to incoming appeals from Medicare appellants in a professional, timely, and accurate manner.
  • Researches and identifies potential claims processing issues.
  • Submits educational referrals as necessary when claims billing errors are noted to decrease redeterminations and allow claims to pay at the lowest level of appeal.
  • Identifies processing deficiencies and initiates corrective action.
  • Assists in writing and updating processing guidelines.
  • Identifies internal/external education and/or training needs.
  • Adapts to changes.
  • Communicates information to appropriate internal and external parties in a timely manner.
  • Meets or exceeds performance standards consistently.
  • Problem solves and researches effectively.
  • Processes overpayment appeals as needed.
  • Writes redetermination decision letters in accordance with CMS standards.

Non-Essential Duties and Functions
  • Other duties as assigned.

Requirements

Qualifications

Minimum Qualifications:
  • High school diploma or GED
  • 6 months' work related experience
  • General PC knowledge
  • Prioritization Skills

Preferred Qualifications:
  • 1 year work related experience

Environment and Cognitive/Physical Demands
  • Office Environment
  • Ability to read, hear, speak, keyboard, reason, communicate effectively and problem solve
  • Requires prolonged sitting and telephone usage
  • Requires the use of office equipment such as computer terminals, telephones, copiers and printers
  • Infrequent lifting up to 15 pounds
  • Infrequent stooping


Segregation of Duties

Every employee is responsible to perform their duties and responsibilities in accordance with Noridian values, policies and procedures, including but not limited to, Segregation of Duties Principles, HIPAA Security and Privacy, CMS requirements, the Noridian Compliance Program, and any other applicable laws, rules and regulations.

Statement of Other Duties

This document describes the essential functions, requirements, and responsibilities of this job, and is not intended to be a complete list of all tasks and functions. Employees may be requested to perform job related tasks other than those specifically listed in this description, and may be required to perform any task requested by the supervisor or by management.

CMS Access Compliance and Regulation Contingency Statement

Some positions require compliance with (i) federal and agency-specific regulations and related clauses included in NHS's prime contracts with the Government, (ii) background checks, and (iii) eligibility for a government-issued identification card.

Other Information

Job Posting Policy 6.05

New employees with Noridian Healthcare Solutions will be eligible to apply for positions within their assigned department after successfully completing a 90-day review. For positions outside your department, you must attain a minimum of six months of service before you can apply.

Equal Employment Opportunity

Equal Opportunity Employer of Minorities, Females, Protected Veterans and Individual with Disabilities, as well as Sexual Orientation or Gender Identity.

For questions, please email careers@noridian.com.

This job posting will be closed 10/3/2018 at 8:00AM CST. No further applications will be considered.



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