Reviews appeals and determines the proper protocol. Works with management to ensure correct interpretation of Medicare rules and regulations are being followed and by performing the following duties.

1. Makes reconsideration determinations for disputes between enrollees and a managed care organization.
2. Reviews cases to determine and summarize facts of each case assigned and assesses issues involved in the case.
3. Reviews file to determine whether all relevant information has been submitted.
4. Prioritizes issues if more than one issue is involved.
5. Researches issues using federal and state law, federal and state regulations, relevant contract law and other sources as defined by the client contract.
6. Identifies whether case requires review by independent physician consultant.
7. Outlines pertinent facts and issues for review by independent physician consultants.
8. Acquires all necessary information involving cases and renders a determination based on the information.
9. Communicates the determination in a clearly written letter and ensures that the letter is sent to all appropriate parties as required by the specific client contract.
10. Collects and ensures that all data collected in a case file is accurate.
11. Maintains the case file in appropriate order so that others (i.e. re-openings, ALJ) can easily understand the file.
12. Performs other special projects not related to a specific case such as general legal research, general medical research, drafting proposal sections, or acting as a liaison for a specific project, when necessary.
13. Possibility of occasional or rotating weekend coverage.

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Education/Experience

RN or higher clinical degree (e.g. RPh and MD) and/or legal degree (e.g. JD); or equivalent combination of education and experience.

 Language Ability

Ability to add, subtract, multiply, and divide in all units of measure, using whole numbers, common fractions, and decimals. Ability to compute rate, ratio, and percent and to draw and interpret bar graphs.

Reasoning Ability

Ability to apply common sense understanding to carry out instructions furnished in written, oral, or diagram form.  Ability to deal with problems involving several concrete variables in standardized situations.

Computer Skills

To perform this job successfully, an individual should have knowledge of Microsoft Word; Microsoft Excel; Microsoft Explorer; Microsoft Outlook.

Physical Demands

While performing the duties of this job, the employee is regularly required to sit; use hands; reach with hands and arms and talk or hear. The employee is occasionally required to stand; walk and climb or balance.  The employee must occasionally lift and/or move up to 25 pounds. The employee must occasionally lift and/or move up 25 pounds.

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