Medicare Audit/Appeal Specialist

Respiratory Therapist (RT), Licensed Practical Nurse (LPN), Registered Nurse (RN) or Paralegal required.
Current professional licensure or certification as required by the state of residence.
Strong organizational, critical thinking and problem-solving skills.
Customer service oriented.
Proficiency in Microsoft Office Software.

Prepare and submit pre- and post-payment Audits to Medicare programs.
Maintain records of all audit activity.
Collaborate with the Supervisor for appropriate response to audit findings.
Communicate audit observations and findings to improve outcomes.
Review and evaluate patient medical documentation independently to determine if records meet Medicare Coverage policy criteria for Respiratory Health Products for reimbursement.
Prepare and submit persuasive appeal request to Medicare (redetermination, Reconsiderations and Administrative Law Judge (ALJ)).
Provide superior customer experience in discussing payer policies, coverage criteria, benefit limitations, potential cost, and any pertinent product information with patients and healthcare teams.
Prioritize workload based on clinical strength of cases and potential for payment.
Maintain understanding of department policies and procedures.
Work with internal departments and/or communicate directly with prescribing and/or primary care clinics as needed to gather clinical information necessary to support appeal.
Identify appropriate resolutions for files if denials are upheld.
Identify payer trends and establish payer-specific strategies.
Initiate the pick-up process, when necessary.
Perform other duties and projects as assigned.