Claims Rep II – GHA Redetermination Rep
Core
Review and adjudicate first-level Medicare appeals (redeterminations) by analyzing claims, medical documentation, and policy to determine medical necessity, coding accuracy, and fee determinations.
Role type
Claims adjudication specialist (Medicare appeals)
Builds
Medicare claim decisions and redetermination notices for providers and beneficiaries
Domain
Healthcare administration / Medicare compliance
Deliverable
production ML models | product features | dashboards & analysis | research | client delivery | infrastructure | physical/clinical work
Required skills
Medicare regulations knowledge, claims processing, medical terminology, coding elements review, fee determination, letter writing, system navigation, overpayment calculation, fraud identification
Preferred skills
Recent Medicare experience (2+ years), appeals knowledge, customer service, medical billing
Technologies
Word, web portals, electronic letter writing systems, CMS systems
Responsibilities
Review processed claims against Medicare Policy and edit/audit details; Refer cases to appeal nurses for clinical judgment; Complete decision letters and claim adjustments; Resolve error edits, audits, and code changes; Identify and report overpayments and potential fraud; Assist providers with Medicare regulations and claim submission; Meet CMS performance metrics.
Seniority
Entry-level to Junior, hands-on IC
