Appeals Professional III (Licensed Clinician)
RemoteUnited States
Job Summary
Review medical records and case files to write clear, impartial reconsideration decision letters that support determinations based on medical evidence, statutes, and regulations. Make sound, independent second-level determinations for Medicare Part C appeals while ensuring all issues raised by beneficiaries, representatives, and providers are addressed. Conduct research using federal regulations, contract policies, and medical literature to complete accurate decisions, and participate in case-specific discussions, workgroups, and quality audits. Mentor staff, serve as a subject matter expert, and perform special projects as assigned. Requires an active, unrestricted RN, PT, RT, OT, or other qualifying licensed healthcare professional license. This remote role involves rotating weekend and holiday hours in Eastern, Central, or Mountain Time Zones.
Required Qualifications
- Active, unrestricted license in good standing as an RN, PT, RT, OT, or other qualifying licensed healthcare professional
- Candidates must be based in the United States
- Candidates must be able to work Eastern, Central, or Mountain Time Zone business hours
- Availability to work on a rotating schedule on weekends and holidays
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