Medical Consultant Eligibility Contractor Review 240822

POSITION DESCRIPTION:

The Medical Consultant will be responsible for the retrospective review of Medicare denials for Part A inpatient hospital stays under the Alexander vs. Azar ruling to determine eligibility for appeal.

This position will solely support the scope of work for the Eligibility Contractor period of performance only. The period of performance is slated to run for approximately 18 months. Position is contingent on contract award.

JOB RESPONSIBILITIES:

· Perform independent review of requests for retrospective appeals associated with Medicare denials for Part A inpatient hospital stays. Determine eligibility for retrospective appeals using case specific medical records as they pertain to Condition Code 44 and/or transition from inpatient to outpatient status.

· Provide written summary for eligibility determination or initiate additional documentation requests, as needed, for retrospective review.

· Monitor timeliness of reviews to ensure required CMS standards are attained.

· Coordinate and assist in the development and maintenance of written procedures for consistency of reviews and training of any required personnel.

· Meet or exceed all performance standards established for this position.

· Perform other duties as assigned by management.

EDUCATION/EXPERIENCE:

Per the contract, this individual may be a coding or clinical team member.

Education Required: Registered Nurse or coding certificate through an approved American Academy of Professional Coders (AAPC), American Health Information Management Association (AHIMA) or other approved coding certification program.

Licenses and/or Certifications Required: RN with active license in SC or Registered Health Information Technician (RHIT), Registered Health Information Administrator (RHIA), Certified Coding Specialist (CCS), Certified Professional Coder (CPC), or Certified Professional Coder-Hospital (CCP-H)

Experience Required: Two years of clinical or coding experience. One year of medical review experience.

Skills/Knowledge Required:

· Individual must have expertise and capabilities in reviewing hospital records or other medical documentation. The individual should be able to review records and claims data to identify whether a condition code 44 is on the related claim or if there is other documentation or notation in the record that denotes a change from inpatient to outpatient status for the beneficiary (e.g., utilization committee decision or other notation in the claim documentation or medical records).

· Demonstrated excellent research and writing skills.

· Expertise in reviewing inpatient hospital records or other medical documentation.

· Ability to perform comfortably in a fast-paced, deadline-oriented work environment and successfully execute several tasks simultaneously.

· Proficiency with Microsoft Word and Excel.

· Ability to maintain confidential and sensitive information.

· Prefer subject matter expertise in Part A Medicare hospital billing/coverage. Medicare medical review or appeals experience a plus.