Medical Reviewer Ii, Dispute Resolution

Position Purpose:

Medical Reviewer II performs complex (senior-level) work. Provides dissatisfied patients/beneficiaries and/or providers the opportunity to present documentation to demonstrate why an appeal/dispute should be allowed. Provides an independent second level determination/Dispute Resolution based on the documentation, facts, laws, regulations, and guidelines. Works under general supervision, with moderate latitude for the use of initiative and independent judgment.

Essential Responsibilities:

• Reviews medical records/case file, writes a reconsideration/Dispute Resolution 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.
• Responds to and ensures that all appeal/dispute issues raised by the beneficiary/patient, representative, and provider/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.
• Participates in case specific verbal discussions.
• Conducts reviews of appeals/disputes with multiple beneficiaries/services in one case.
• Plans responses to statistical analysis challenges with assistance from statisticians.
• Attends meetings and 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.

Minimum Qualifications

Education

• Associate's degree or 60 or more credit hours towards a Bachelor’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.)

Experience

• Three (3) years of medical Dispute Resolution or 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
• Experience directly relevant to the specific task order or project

Location

Remote-U.S. Only

CMS Contract requires residence in the U.S. at least 3 out of the past 5 years.

Knowledge, Skills and Abilities

Considerable 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

• Researching, analyzing and interpreting policies and state and federal laws and regulations

Proficient skill in

• Prioritizing and organizing work assignments

• The use of personal computers and applicable programs, applications and systems

Ability to

• Multitask and meet deadlines
• 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

Why J29?

J29 is an employee centric Federal Contractor that focuses on creating health and IT solutions for the better of the community. Making company culture the main priority ensures employees satisfaction and retention. We believe in empowering employees to do great things. When you invest in your people, and focus on creating a healthy work life balance, then your employees will take care of your customers and make sure they are happy. One of our sayings is “Work Hard and Be Nice to People” – it really is that simple.

J29 Solutions

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EEO Statement

J29, Inc. provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.

This policy applies to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation and training.