Reconsideration Analyst I

Tmf Health Quality Institute - Jacksonville, FL

Part-time - Entry Level

Jacksonville, FL

Religious, Grantmaking, Civic, Professional, and Similar Organizations

About the position

The Reconsideration Analyst I position at C2C Solutions, Inc. is a remote role that focuses on performing routine appeals work related to reconsiderations and dispute resolutions. This position serves as a support person for the reconsideration and dispute resolution professionals, as well as physician reviewers, specifically for second-level reconsiderations and dispute resolutions. The role operates under close supervision, allowing minimal latitude for the use of initiative and independent judgment. In this role, the analyst will coordinate the delivery of re-determination files and dispute resolution documents, ensuring that all necessary information is accurately processed and communicated between external entities and the internal team. A critical aspect of the job involves building a comprehensive reconsideration or dispute resolution case file from the evidence submitted and received. The analyst will analyze each case to ensure it meets the requirements for a valid reconsideration or dispute resolution request as mandated by the Centers for Medicare and Medicaid Services (CMS) or other customer entities. The analyst will also be responsible for making decisions based on the type of case—whether medical or non-medical—along with the appeal or review categories, the validity of the appeal or dispute resolution request, and the documentation related to dispute resolution settlements. Additionally, the role requires inputting appropriate data regarding reconsiderations and dispute resolution cases into the necessary systems and responding to requests from appellants, patients, and providers regarding reconsideration and dispute reviews.

Responsibilities

• Coordinates the delivery of re-determination files and dispute resolution documents and decisions from and to external entities.
• Builds a reconsideration/dispute resolution case file from evidence submitted and received.
• Analyzes each case to ensure it meets the requirements for a valid reconsideration/dispute resolution request as mandated by CMS or other customer entities.
• Analyzes and makes decisions based on medical vs. non-medical case type, appeal/review categories, validity of appeal/dispute resolution request, and dispute resolution settlement documentation.
• Inputs appropriate data regarding reconsiderations/dispute resolution cases into the applicable required systems.
• Responds to reconsideration/dispute review requests from appellants, patients, and providers.

Requirements

• High School Diploma or equivalent.
• One (1) year of general office experience.
• College education or technical training in administration, business, or related areas may be substituted for experience on a year per year basis.
• Medicare experience is preferred.

Benefits

• Medical insurance
• Dental insurance
• Vision insurance
• Life insurance
• Accidental death and dismemberment insurance
• Short and long-term disability insurance