Dispute Resolution Reviewer 1 (Medical Reviewer)

Job Description

Job Description

Position Purpose :

Performs complex (journey-level) work. Provides dissatisfied beneficiaries and / or providers the opportunity to present documentation to demonstrate why an appeal should be allowed. Provides an independent second level determination based on the documentation, facts, laws, regulations, and guidelines. Works under general supervision, with moderate latitude for the use of initiative and independent judgment.

Essential Responsibilities :

• Reviews medical records / case file, writes a reconsideration decision that is clear, concise, and impartial and supports the determination made, and documents review.
• Makes sound, independent decisions based on medical evidence in accordance with statutes, regulation, rulings, and policy.
• Responds to and ensures that all appeal issues raised by the beneficiary, representative, and supplier have been addressed.
• Provides a fair and impartial decision based on current evidence, regulations, policies, and
• Conducts research using online federal regulations, contract policy, standards of medical practice, contract manuals, coverage issues manuals, medical literature, and other related resources to complete an accurate and well-supported decision.
• Stays abreast of changes in regulations, medical and healthcare practices, policies and
• Participates in special projects and performs other duties as

Minimum Qualifications :

Education

Additional experience in Medicare appeals, medical review, clinical, or other related experience in a healthcare setting may be substituted for Associate’s degree on a year per year basis. (Experience requirements may be satisfied by full-time experience or the prorated part-time equivalent.)

Experience

Knowledge, Skills and Abilities :

Working knowledge of

Proficient skill in

Ability to

Why J29?

J29 is an employee centric Federal Contractor that focuses on creating health and IT solutions for the better of the community.  Making company culture the main priority ensures employees satisfaction and retention. We believe in empowering employees to do great things. When you invest in your people, and focus on creating a healthy work life balance, then your employees will take care of your customers and make sure they are happy. One of our sayings is “Work Hard and Be Nice to People” – it really is that simple.

EEO Statement

J29, Inc. provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.

This policy applies to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation and training.

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