Reconsiderations Analyst III (RA III)

Position Purpose:

The Reconsideration Analyst III (RA III) role is responsible for performing complex (journey-level) appeals work to process reconsideration appeals for Medicare beneficiaries. Makes second level non-medical appeal decisions for beneficiaries, supplies, or providers. This may include cases dismissed by a contractor, traditional appeals, or Expedited appeals. This role, while being supervised, will be responsible for frequent inbound and outbound calls to beneficiaries.

Essential Responsibilities:

• Writes a reconsideration decision that is clear and supports the determination made.
• Ensures that all appeal issues raised by the beneficiary, representative, supplier, and/or provider have been addressed.
• Provides a fair and impartial decision based on current evidence, regulations, policies, and procedures.
• Ensures all documents are releasable and do not violate any Privacy Act provisions.
• Organizes documents by dates of service relevant to the charges, research denials and regulations used and ensure that any overpayment calculation is correct.

• Conducts research using online federal regulations, contract policy, standards of medical practice, contractor manuals, coverage manuals, and other related resources to complete an accurate and well supported decision.
• Makes sound, independent decisions based on the submitted evidence in accordance with statutes,
• regulation, rulings, and Centers for Medicare and Medicaid Services (CMS) policy.
• Stays abreast of changes in regulations and practices, policies and procedures.
• Responsible for verbal and/or written notification of appeal decision to beneficiaries and providers of service.

• Responds to telephonic and/or written inquiries from appellants.
• Builds a reconsideration case file from evidence submitted and received. Analyzes each case to ensure it meets the requirements for a valid reconsideration request as mandated by CMS.
• May participate in Pre-decisional Appellant Discussions for the purpose of allowing the appellant to be heard and submit additional documentation.
• May provide subject matter expertise for Reconsideration Analysts regarding issues being appealed by dissatisfied beneficiaries or suppliers.
• May be responsible for verbal intake of appeals, returning voicemail inquiries, and issuing verbal decisions.

• Participates in special projects and performs other duties as assigned.

Minimum Qualifications:

• High School Diploma or equivalent
• Three (3) years of general office experience

• Inbound and outbound call handling related to medical claims
• College education or technical training in administration, business, or related areas may be substituted for experience on a year per year basis. (Education requirements may be satisfied by full-time education or the prorated part-time equivalent.)
• Two (2) years of Medicare Appeals or Managed Care appeals
• Experience directly relevant to the specific task order or project, preferred

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

• Customer service etiquette
• Research techniques
• Medicare appeals program

• Applicable systems and applications
• Applicable laws, rules and regulations

Proficient 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

• Meet production and quality standards
• 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.

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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.