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Medical Appeals Specialist (SCA)
Job Code:2022-53-4R-001
Location:San Angelo, TX (Remote)
Status:Regular Full Time
Pay Range:19.00-23.00
  
Responsibilities:
Candidates must be available for Teleworking from the following location(s): San Angelo, TX (Tom Green County, TX)

The Medical Appeals Specialist performs reconciliation of appeals received from the Provider/MAC, as well as serving as a critical point of contact between the MAC and other internal departments within Performant. As the Medical Appeals Specialist, you will join a team of experienced medical auditors. You will work in a fast paced and dynamic environment and be part of a multi-location team. The successful candidate will be a team player able to collaborate with a variety of different entities to solve problems and generate solutions.

• Applying appropriate Medicare policy and rules
• Documenting all findings referencing the appropriate policies and rules
• Generating letters articulating outcomes as needed
• Working collaboratively with the audit team to identify and obtain approval for particular vulnerabilities and/or cases subject to potential abuse
• Work in partnership with CMS, CMD colleagues, MAC’s and other Medicare contractors on improving Medicare policies, provider education, and system edits
• Collaborate policies and procedures pertinent to the RAC review process
• Keep abreast of medical practice, changes in technology, and regulatory issues that may affect the RAC contract
• Work with the project team to minimize appeals
• Suggest ideas that may improve work flow
• Attend MAC meetings as scheduled
• Assist with training review team members
• Interface with and support the Medical Director
• Cross train in all departments/areas as requested
Required Skills and Knowledge:

Additional Requirements:

•Ability to obtain and maintain client requiredclearances as well as pass company regular background and/or drug screening.

•Completion of Teleworker Agreement upon hire, andadherence to the Agreement (and related policies and procedures) including, butnot limited to: able to navigate computer and phone systems as a user to workremote independently using on-line resources, must have high-speed internetconnectivity, appropriate workspace able to be compliant with HIPAA, safety& ergonomics, confidentiality, and dedicated work focus withoutdistractions during work hours.

 

Physical Requirements:

Available for hire Teleworking in the following arealocations:  San Angelo, TX (Tom Green County, TX)

**NOTE: Must be able to meet requirements for andperform work assignments in accordance with Company policies and expectationson a home remote basis (and must meet Performant remote-worker requirements)until at which time staff may be notified and required to work from aPerformant office location on an ad-hoc or periodic basis.

Basic office equipment required to perform remote workis provided by the company.

•Job is performed in a standard busy office environmentwith moderate noise level (or may be home-office setting subject to Companyapproval and Teleworker Agreement), sits at a desk during scheduled shift, usesoffice phone or headset provided by the Company for calls, making outboundcalls and answering inbound return calls using an office phone system; views acomputer monitor, types on a keyboard and uses a mouse.

•Reads and comprehends information in electronic(computer) or paper form (written/printed).

•Sit/stand 8 or more hours per day; has the option tostand as needed while on calls; reach as needed to use office equipment.

•Consistently viewing a computer screen and typesfrequently, but not constantly, using a keyboard to update accounts.

•Consistently communicates on the phone as requiredprimarily within the department and company and may include client contacts orother third-party depending on assignment with account holders, may dialmanually when need or use dialer system; headset is also provided.

•Occasionally lift/carry/push/pull up to 10lbs.


Education and Experience:

• Experience with ICD-9, CPT-4 or HCPCS coding.
• Knowledge of the Medicare program, particularly the coverage and payment rules.
• Ability to maintain high quality work while meeting strict deadlines.
• Excellent written and verbal communication skills.
• Not currently sanctioned or excluded from the Medicare program by the OIG.
• Knowledge of appeals processes
• Knowledge of claims processing
• Must be able to independently use standard office computer technology (e.g. email telephone, copier, etc.) and have experience using a case management system/tools to review and document findings.
• Must be able to manage multiple assignments effectively, create documentation outlining findings and/or documenting suggestions, organize and prioritize workload, problem solve, work independently and with team members.
• Strong knowledge of medical documentation.
• Courteous, professional, and respectful attitude.
• Possess knowledge of CMS rules and regulations.
• Flexibility to handle any non-standard situations that may arise.
• Must be able to multi task.
• One or more years experience in health care claims that demonstrates expertise in Medicare claims data such as for medical billing experience for an Insurance Company or hospital required.
• Knowledge of appeals processes
• Claim processing experience


Other Requirements:

 Performant is a Government contractor and subject tocompliance with client contractual and regulatory requirements, including butnot limited to, Drug Free Workplace, background requirements, and clearances(as applicable).

•Must submit to and pass pre-hire background check, aswell as additional checks throughout employment.

•Must be able to pass a criminal background check; mustnot have any felony convictions or specific misdemeanors, nor on state/federaldebarment or exclusion lists.

•Must submit to and pass drug screen pre-employment (andthroughout employment).

•Performant is a government contractor. Certain clientassignments for this position requires submission to and successful outcome ofadditional background and/or clearances throughout employment with the Company.

 

Employment VISA Sponsorship is not available for thisposition

Job Profile is subject to change at any time.

 

EEO

Performant Financial Corporation is an Equal OpportunityEmployer.

Performant Financial Corporation is committed tocreating a diverse environment and is proud to be an equal opportunityemployer. All qualified applicants will receive consideration for employmentwithout regard to race, color, national origin, ancestry, age, religion,gender, gender identity, sexual orientation, pregnancy, age, physical or mentaldisability, genetic characteristics, medical condition, marital status,citizenship status, military service status, political belief status, or anyother consideration made unlawful by law.

 

NO AGENCY SUBMISSIONS WITHOUT PERFORMANT AUTHORIZEDAGENCY AGREEMENT AND APPROVED PERFORMANT JOB ORDER5.