Appeals Professional II

**Please make sure your application is complete, including your education, employment history, and any other applicable sections. Initial screening is based on the minimum requirements as defined in the job posting, such as education, experience, licenses, and certifications. Your experience should also address the knowledge, skills and abilities needed for the role. Incomplete applications will not be considered.***This position is located Remote United States*Position Purpose:Provides dissatisfied parties to a Medicare appeal the opportunity to present documentation or evidence to demonstrate why an appeal should be allowed. Provides an independent second level determination based on the documentation, facts, laws, regulations, and guidelinesEssential Responsibilities:Responsible for significant or complex programs, may assist with quality reviews and audits.Reviews medical records/case file, writes a 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 issues raised by the beneficiary, representative, supplier, and provider have been addressed.Provides a fair and impartial decision based on current evidence, regulations, policies, and procedures.Minimum QualificationsEducationAssociate's degree or 60 or more credit hours towards a Bachelor's degree from an accredited college or university in healthcare or related disciplineAdditional 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.)ExperienceThree (3) years of Medicare appeals, medical review, clinical, healthcare regulatory interpretation/application, healthcare compliance or related experience in a healthcare settingExperience directly relevant to Medicare managed care appeals or utilization management activities, preferredResided in the United States for a minimum of three (3) years out of the last five (5) years (Per Contract Requirement)BenefitsC2C offers an excellent benefits package, including:Medical, dental, vision, life, accidental death and dismemberment, and short and long-term disability insuranceSection 125 plan401KCompetitive salaryLicense/credentials reimbursementTuition ReimbursementEOE Vet/DisabilityEqual Opportunity Employer/Protected Veterans/Individuals with Disabilities