MISSION:
The mission of BAC Enterprises is to provide persons with disabilities innovative services and opportunities to achieve personal success.
JOB SUMMARY:
Under general supervision, examines incoming Medicare redetermination appeals by reviewing documentation, claim history, and applicable guidelines to make appeal determinations. Determines whether adjustments within standard systems are appropriate and responds to Medicare appellants while supporting accurate administration of CMS regulations and proactive customer satisfaction.
ESSENTIAL FUNCTIONS:
- Conducts redetermination reviews in accordance with Medicare rules, regulations, and established guidelines.
- Responds to incoming appeals from Medicare appellants in a professional, timely, and accurate manner.
- Prepares, proofreads, and issues correspondence in accordance with current guidelines.
- Researches and identifies claims processing deficiencies and initiates appropriate corrective responses.
- Evaluates documentation, claim history, and policy criteria to support accurate and compliant appeal processing.
- Submits educational referrals as necessary to reduce redeterminations and support claims resolution at the lowest appropriate level of appeal.
- Assists with writing, reviewing, and updating processing guidelines.
- Identifies internal or external education and training needs, communicates findings, and assists with training as necessary.
- Communicates information to appropriate internal and external parties in a timely manner.
- Researches issues, analyzes information, and problem-solves effectively.
- Processes overpayment appeals as assigned.
- Maintains current knowledge of working systems, processing instructions, CMS requirements, Joint Operating Agreement requirements, and other relevant resources.
- Performs other duties and special projects as assigned.
- This position has no formal supervisory responsibility. May coordinate work activities, provide workload guidance, and support training or reporting activities as assigned.
MINIMUM QUALIFICATIONS:
- High School Diploma or equivalent.
- Minimum of six (6) months of work-related experience.
- Must successfully pass all required pre-employment screenings, including a drug screening.
- Ability to obtain and maintain any required access approvals, credentials, or background clearances applicable to the assigned contract or work location.
PREFFERRED QUALIFICATIONS:
- Experience with Medicare claims, appeals processing, healthcare administration, customer service, or records review.
In addition to meeting the minimum qualifications listed above, an individual must be able to perform each of the established essential functions in order to perform this job successfully.
KNOWLEDGE, SKILLS, AND ABILITIES:
- General PC knowledge and ability to work within standard business systems.
- Strong prioritization, analytical, and communication skills.
- Ability to adapt to changes in guidelines, systems, workloads, and business needs.
- Ability to review documentation and apply policies, procedures, and guidelines accurately.
- Ability to prepare clear, accurate, and professional written correspondence.
- Ability to research issues, identify deficiencies, and recommend corrective responses.
- Ability to maintain confidentiality and handle sensitive information appropriately.
- Strong attention to detail and commitment to quality and compliance.
CERTIFICATIONS, LICENSES and REGISTRATIONS:
- Not applicable.
TRAVEL:
No overnight or out-of-area travel is expected for this position. Local movement within local sites will be required to support inspections, meetings, incident response and contract operations.
PHYSICAL REQUIREMENTS:
Employees must be able to perform the essential physical requirements of the position, with or without reasonable accommodation, for extended periods of time. Duties may include:
- Sitting or standing for extended periods while performing computer-based work.
- Using hands and fingers for keyboarding, data entry, document review, and other office tasks.
- Viewing computer screens, reports, electronic records, and other written materials for extended periods.
- Communicating verbally and in writing with supervisors, coworkers, customers, and other stakeholders.
- Lifting, carrying, or moving standard office materials and equipment weighing up to 25 pounds.
These physical requirements may be performed with or without reasonable accommodation.
SAFETY AND ENVIRONMENTAL REQUIREMENTS:
Work is performed primarily in an office or remote office environment using standard office equipment and computer systems.
Employees may experience routine office noise, interruptions, deadlines, and extended periods of computer-based work.
Employees are required to comply with company safety policies, information security requirements, confidentiality standards, and established procedures.
SENSORY REQUIREMENTS:
Requires visual acuity, manual dexterity, concentration, attention to detail, and the ability to read, review, enter, and verify information accurately using computer systems.
Availability: Full Time Remote
Candidates must reside within 55 miles of Rockledge Florida
Schedule: Monday-Friday (shift times between 8 am and 8 pm)
Salary: $17.77/hr.
Benefits:
- Free medical, dental, and vision insurance for employees, and a buy-up option is available.
- Medical opt-out plan is available for qualified employees.
- Paid holidays and sick time.
- Paid vacation is available after one year of employment, based on the number of hours worked
- Full-time employees are eligible to participate in the 401k plan on the first of the month following their date of hire.
- Additional Supplemental benefits are available, including Accident, Critical Illness, Short Term Disability, and Hospital.
- Employee Assistance Program.
Accepting applications until positions filled...
Applications may be completed through our website: https://bacemploy.com
*A completed application is required*
BAC
Providing innovative services for individuals with disabilities to achieve personal success!
Qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, disability or protected veteran status. We are a Drug-Free Workplace,
High school diploma or equivalent and at least six months of work-related experience. Requires analytical, communication, prioritization, documentation review, policy application, confidentiality, and computer skills.
Key Responsibilities
- reviewing appeals
- researching claims
- preparing correspondence
Job Details
- Category: Legal and Compliance
- Seniority: No Prior Experience Required
- Commitment: Full Time
- Workplace: Remote — Rockledge, Florida, United States
- Salary: USD 36,961 – 36,961 / year
- Languages: English
Benefits
- Retirement plan
About BAC Enterprises
A nonprofit organization providing innovative services and opportunities for individuals with disabilities. — Industry: Non-Profit Organizations and NGOs