Appeals Representative-Prior Authorization (Novitas) - Remote, FL

SUMMARY STATEMENT
Team members are accountable for conducting a review of Medicare Part A or B claims on services questioned on appeal by a provider, facility, beneficiary, Centers for Medicaid and Medicare Services (CMS) or other interested parties using multiple computer applications. Incumbents render appeals decisions based on research of the initial claim processing activity, documented procedures and policies and information supplied with the appeal request and respond to the appeal in the form of an adjustment to payment, refund request for overpayment or a written response upholding the original processing of the service.

ESSENTIAL RESPONSIBILITIES
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. This list of essential job functions is not exhaustive and may be supplemented as necessary.

Respond timely to Medicare inquiries that constitute an appeal or reopening of an initial claim determination: (90%)
* Researches electronic files and imaged records and/or accesses the appropriate external systems such as Multi-Carrier System (MCS), Fiscal Intermediary Standard System (FISS), Medicare Appeals System (MAS) as well as Microsoft Windows applications including Excel files and Word documents.
* Reads and interprets processing guidelines, determines the accuracy of the original claim determination and takes the necessary actions to finalize the case file. Performs claim correction activity of the initial claim determination when an additional payment or a reduction in payment correction is necessary.
* Reviews additional documentation (e.g., office notes, test results, medical records, etc.) submitted with the request to determine if this information should be forwarded to a clinician for additional consideration or utilize the additional documentation to make the redetermination decision.

Resolves adjustment claims which suspend due to system edits/audits or have been returned to the department from entities conducting subsequent levels of review. (10%)

Performs other duties as the supervisor may, from time to time, deem necessary.

REQUIRED QUALIFICATIONS
* High School diploma or GED
* 2 years' experience utilizing research skills in reading and interpreting information
* PC experience in Microsoft Windows or similar environment -- includes Word, Excel, PowerPoint, etc.
* Demonstrated verbal and written communication skills
* Demonstrated customer service skills
* Demonstrated ability to make independent decisions relating to claims processing accuracy relying on various on-line reference tools

PREFERRED QUALIFICATIONS
* Sound research and decision-making skills to respond to the inquiry in accordance with Medicare procedures and guidelines
* Demonstrated knowledge of Medicare policies and benefits, internal processing instructions, as well as medical terminology
* Medicare claims processing experience or a medical background
* Knowledge of Medicare processing systems

Background Investigation: If you are selected for this position, you must undergo a pre-employment Background Investigation, Drug Screen, and Identity Proofing documentation must be cleared prior to hire. Most positions are subject to additional Identity Proofing, Fingerprinting and additional Background Investigation screening conducted by the Federal Government to be granted Enterprise User Administration (EUA) system logical access after you begin your employment. Your continued employment is contingent upon the outcome of the complete additional screening criteria required for the position which must find that you meet the applicable government customer's requirements (e.g., suitable for access to CMS information and information systems), as well as any additional investigation which may be required throughout your employment. If you are found not suitable, your employment may be subject to corrective action, up to and including immediate termination of employment.

Identity Documentation: You must have access to a current and unrestricted REAL ID, U.S. Passport, U.S. Passport Card, Foreign Passport, or U.S. Permanent Residency Documents. Note: Employment Authorization Cards (EAD) are not a substitute for Visas or U.S. Permanent Resident Cards.