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Years of Experience
Date Last Verified
Supervisor - Appeals The candidate will be responsible for reviewing Administrative Law Judge (ALJ) decisions to determine whether a synopsis of perceived error(s) is appropriate and, if so, forwards the synopsis to the CMS COR as a monthly deliverable. Reviews all Part C written inquiries and completes post-adjudication determination decision letters for disputes between providers and/or enrollees, and Medicare. Assists in legal analysis and provides coaching and procedural instructions for variety of staff as requested. Serves as be the Policy Subject Matter Expert (SME) for the Part C QIC Project. Supervise team members ensuring members follow firm policies and procedures. Assist members when necessary in coordination of appeal case processing and workload correction. Conduct periodic quality review of team members’ work product. Lead periodic team meetings to discuss team related issues and concerns. Perform reopening’s and all essential post-adjudication responsibilities. Serve as the Policy Subject Matter Expert for the Part C QIC Project. Manage Administrative Law Judge (ALJ) activities for Part C including participating in hearings as necessary. Ensures coverage dispute reconsideration meet applicable quality standards; performs quality assurance reviews of certain reconsideration determinations. Reviews and Updates Part C specific Policy materials as appropriate and documents; communicates across the department where appropriate. Represents the Part C QIC on the QIC Change Control Committee. Participates in ALJ (Administrative Law Judge) hearings to explain and defend reconsideration decisions; both as a party and non-party; processes reconsideration reopening, vacated dismissals and ALJ remands. Responds to outside inquiries of concerns regarding decided reconsidered determinations. Performs special projects not related to a specific case such as general legal research; general medical research, drafting proposal sections or acting as a liaison for a specific project.
Qualification and Experience
The candidate should have 2-3 years’ experience in law office or applicable experience. Must have Juris Doctor from an accredited law school and licensed attorney. RN is preferred. Excellent organizational, interpersonal, written, and verbal communication skills is needed. Proficiency in Microsoft Word and Excel and Internet research is must.
Requisition ID: 2018-30221
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