Redetermination Examiner

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Redeterminations Examiner

The Redeterminations Examiner is responsible for examining incoming Medicare Redetermination appeals through a review of documentation to make appeal determinations. This position determines if adjustments within standard systems are in accordance with established guidelines and policies and responds to Medicare appellants ensuring quality administration of Centers for Medicare and Medicaid Services (CMS) regulations and continuous, proactive customer satisfaction.

• Conducts redetermination reviews per Medicare rules and regulations
• Responds to incoming appeals from Medicare appellants in a professional, timely, and accurate manner. Including letter writing, proofreading with attention to detail following current guidelines.
• Researches and identifies claims processing deficiencies and initiates corrective response
• Evaluates all documentation and history needed to determine if it meets outlined policy criteria to ensure accurate and compliant processing in accordance with CMS guidelines.
• Submits educational referrals as necessary to decrease redeterminations and allow claims to pay at the lowest level of appeal
• Assists in writing and updating processing guidelines
• Identifies internal/external education and/or training needs, communicates findings, and assists in training if necessary
• Communicates information to appropriate internal and external parties in a timely manner
• Problem solves and researches effectively
• Process overpayment appeals as needed
• Maintain up-to-date knowledge of working systems, processing instructions, and other relevant resources to ensure efficient and accurate appeal processing.
• Maintains knowledge of CMS and Joint Operating Agreement (JOA) requirements

• Other duties as assigned
• May facilitate trainings and/or meetings
• May provide back up support to the Process Team

• High School diploma or GED
• 6 months' work-related experience
• General PC knowledge
• Prioritization skills
• Strong communication skills
• Strong analytical skills
• Ability to adapt to changes

• 1-year redetermination processing experience
• Knowledge of medical terminology, Claims Processing Timelines (CPT), Healthcare Common Procedure Coding System (HCPCS) and ICD coding

• Office Environment
• Ability to read, hear, speak, keyboard, reason, communicate effectively and problem solve
• Requires prolonged sitting and telephone use
• Requires the use of office equipment such as computer terminals, telephones, copiers and printers
• Infrequent lifting to 15 pounds
• Infrequent stooping

Every employee is responsible to perform their duties and responsibilities in accordance with Noridian values, policies and procedures, including but not limited to: Segregation of Duties Principles, HIPAA, Security and Privacy, CMS requirements, the Noridian Compliance Program and any other applicable laws, rules and regulations.

This document describes the essential functions, requirements, and responsibilities of this job, and is not intended to be a complete list of all tasks and functions. Employees may be requested to perform job related tasks other than those specifically listed in this description and may be required to perform any task requested by the supervisor or management.

Health, Dental and Vision Insurance, Voluntary Insurance Plans, Health Savings and Flexible Spending Accounts, 401k and Company Match, Company-paid Life Insurance, Education Assistance Program, Paid Sick Leave, Paid Holidays, Increasing PTO Accrual Plan, Medical/Parental/Disability Leave, Workers Compensation, Retiree Benefits, Severance Package, Employee Assistance Program, Financial and Health Wellness Benefits, Casual Dress, Open Office Setting, and Online Learning System.

Some positions require compliance with (i) federal and agency specific regulations and related clauses included in Noridian's prime contracts with the Government, (ii) background checks, and (iii) eligibility for a government-issued identification card.

An employee in this position may be required to possess a "Federal Identification Card" (Federal ID) as a condition of employment. Federal ID's may include one of the following: Personal Identity Verification (PIV) card, Personal Identity Verification-Interoperable (PIV-I) card, a Local-Based Physical Access Card issued by CMS, or a Local-Based Physical Access Card issued by another Federal agency and approved by CMS. Obtaining a Federal ID and continued eligibility for this position may require the successful completion of a Federal Background Investigation performed by the Federal Government and a residency requirement that you have lived in the United States at least three out of the last five years. Failure to obtain a Federal ID may result in the removal from the position or termination of employment.

Qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, protected veteran status or other characteristics protected by state or federal law.

The contractor will not discharge or in any other manner discriminate against employees or applicants because they have inquired about, discussed, or disclosed their own pay or the pay of another employee or applicant. However, employees who have access to the compensation information of other employees or applicants as a part of their essential job functions cannot disclose the pay of other employees or applicants to individuals who do not otherwise have access to compensation information, unless the disclosure is (a) in response to a formal complaint or charge, (b) in furtherance of an investigation, proceeding, hearing, or action, including an investigation conducted by the employer, or (c) consistent with the contractor's legal duty to furnish information. 41 CFR 60-1.35(c)

Below is the salary range for potential new hires.

Salary Range: The pay range for this position is $17.75 - $23.69 per year (or hourly), however, the base pay offered may vary depending on geographic region, internal equity, job-related knowledge, skills, and experience among other factors.

Other Compensation: Incentive Plan & Lifestyle Benefit

This job will be closed 07/07/2025 at 8:00AM CST. No further applications will be considered.