Appeals Review & Case Handling:
- Review, evaluate, and process appeal requests for Medicare members in compliance with CMS regulations and organizational protocols.
- Conduct thorough case validation and clinical review using sound judgment and medical necessity criteria.
Collaboration:
- Collaborate with onshore payer nurses and Independent Review Organizations (IROs) to collect and verify necessary documentation for appeal resolution.
- Escalate complex cases as needed, providing detailed summaries and clinical insights.
Documentation & Communication:
- Provide clear documentation and clinical rationales for approval or denial decisions.
- Maintain accurate records of all case activities and communicate findings effectively across teams.
Multitasking & Quality Assurance:
- Manage multiple appeal cases concurrently while maintaining high standards for quality and turnaround time.
- Contribute to internal quality assurance reviews and support process improvement initiatives.
Compliance & Industry Standards:
- Stay current on CMS guidelines, UM criteria, and regulatory updates.
- Ensure all appeals are resolved within required timelines and documented appropriately.
Recommended Minimum Skills Requirements (MSRs)
Technical Skills:
- Strong understanding of Medicare UM and Appeals processes.
- Familiarity with CMS guidelines, InterQual/MCG criteria, and clinical review standards.
- Proficiency in using clinical platforms, documentation systems, and Microsoft Office Suite (Word, Excel, Outlook).
Soft Skills:
- Strong case investigation, validation, and critical thinking abilities.
- Excellent written and verbal communication skills in English.
- High attention to detail, empathy, and sound clinical judgment.
Operational and Communication Skills:
- Ability to manage multiple cases and meet CMS-mandated turnaround times.
- Strong organizational, documentation, and time management skills.
- Comfort working with cross-functional teams including payer nurses and IROs.