Medicare Appeals Specialist

Redetermination (Appeals) Specialist

Job summary

The Redetermination (Appeals) Specialist adjudicates first-level Medicare appeals on a post-claim basis, reviewing redetermination requests against Medicare regulations, claims processing rules, and appeal guidelines to reach and document a correct determination. The role produces the Medicare Redetermination Notice (MRN) communicating each decision, determines financial liability, and supports the department in meeting CMS performance metrics.

In this role you will

• Receive, review, and provide written responses (Medicare Redetermination Notice [MRN]) to requests from customers on a post-claim basis in first step of Medicare appeal process.


• Apply knowledge of Medicare regulations, claims processing, and appeal guidelines to determine proper resolution of requests.


• Obtain and review system and hard copy documentation and medical notes. Review and compare processed claims for required coding elements to establish medical necessity, frequency of service, and accurate fee determinations.


• Refer cases to appeal nurses when clinical judgment is required to make decision or is required by audit.


• Determine appropriate resolution to appeal request and adjudicate redetermination decision by resolving all error edits and audits, changing codes, entering allowable amounts, working with other units, pending requests for development, and adjudicating claim to completion.


• Determine appropriate financial liability for decision.


• Develop and complete explanations of decision for MRN decision letter through use of various letter templates, policy information, and input from medical staff.


• Use various technological applications, such as Word, web portal, or electronic letter writing system to generate and revise determination notifications.


• Resolve pended/aged cases, log all requests, and document/update clearly on-line comment file with detail of action taken.


• Research electronic redetermination work processes and reference manuals throughout process of making determinations regarding requests.


• Correspond with Medicare customers to clarify information for claim determination and explain claim adjudication.


• Assist and educate providers on Medicare regulations by utilizing CMS guidelines, publications, and reference materials to ensure correct claim submission. Refer recurrent provider errors to Provider Education for further contact.


• Identify, verify, calculate, and setup overpayment situations. Assist in reporting and recoupment of overpayments.


• Identify and refer potential fraudulent providers and/or beneficiaries to Complaint Screening.


• Refer and forward mis-directed correspondence and unusual claims aberrancies to appropriate area for handling.


• Assist department in meeting CMS performance metrics and minimum quality and quantity standards. Provide back-up for completing staff responsibilities as needed.


• Provide technical assistance by identifying and reporting system problems, testing new enhancements, and other changes as released.

Minimum qualifications

• Must have lived in the United States at least 3 out of the last 5 years. This is a CMS requirement.


• High school diploma or equivalent.

We also prefer

• 2 or more years recent health insurance experience (customer service, claims processing, or medical billing) dealing with coverage and medical necessity determinations.


• Knowledge of MCS/FISS and the MAS systems.

What to Expect Next:

After submitting your application, our recruiting team will review your qualifications. This may include a brief telephone interview or email communication to verify resume details and discuss compensation expectations. Interviews will be conducted with the most qualified candidates. Broadway Ventures conducts background checks and drug testing prior to the start of employment. Some positions may also require fingerprinting.

Broadway Ventures is an equal opportunity employer and a VEVRAA federal contractor. We do not discriminate against applicants or employees on the basis of race, color, religion, sex, national origin, age, disability, protected veteran status, or any other status protected by applicable law.

Reasonable accommodations are available for applicants with disabilities. Broadway Ventures utilizes the OFCCP-approved Voluntary Self-Identification of Disability Form (CC-305).

The pay range shown is a good-faith estimate of the compensation Broadway Ventures reasonably expects to pay for this position at the time of posting. It is not a guarantee of any particular wage, salary, or total compensation. Actual pay offered depends on job-related factors, which may include skills, experience, education, certifications and licensure, geographic work location, contract funding and budget. For positions covered by the Service Contract Act, pay is also governed by the applicable Department of Labor wage determination, which the government may revise.

Some positions are posted in support of a contract proposal that has not yet been awarded. Where that is the case, the position and its final compensation are contingent upon award of the contract to Broadway Ventures and on the terms of the awarded contract, including any government-approved labor rates and the applicable wage determination.

Broadway Ventures offers a comprehensive benefits package. A general description of benefits is below.

• 401(k) and company match


• PTO that grows the longer you stay


• Health, Vision, Dental


• Company provided Life Insurance and Voluntary Life Insurance


•  Short Term Disability and Long Term Disability