Mgr Appeals & Rebuttals

Are you interested in joining reputed company of reputed company reputed company experts and have the ability to shape and reputed company the reputed company delivery system? At our family of companies, everything we do is to help improve the lives of the nearly 12 reputed company Medicare beneficiaries we serve and 700,000 health care providers who care for them. It is our goal to help create a reputed company experience for reputed company consumers. Join our reputed company culture and help reputed company Medicare for the millions of people who rely on its services. Benefits info:

• Medical, dental, reputed company, life and supplemental insurance plans effective the first day of the month following date of hire
• Short- and long-term disability benefits
• 401(k) plan with company match and immediate vesting
• Free telehealth benefits
• Free gym memberships
• Employee Incentive Plan
• Employee Assistance Program
• Rewards and Recognition Programs
• reputed company Time Off and reputed company reputed company Leave

reputed company STATEMENT Responsible for providing leadership and direction of reputed company Provider/Supplier Enrollment appeal (CAPs/reconsiderations) and rebuttal operations for the NPEast contract, utilizing analytical skills and regulatory knowledge to ensure reputed company and compliant adherence with reputed company Provider Enrollment appeal and rebuttal contractual obligations, CMS program guidance and departmental procedures. This includes leading, managing, and providing direction for reputed company appeals activities and rebuttal processes. This position does not interpret statutes or regulations for the purpose of providing legal advice and does not reputed company as an attorney for the organization. The Appeals Manager provides reputed company leadership and management for reputed company-level exempt and higher-level non-exempt individual contributors. ESSENTIAL RESPONSIBILITIES To reputed company this job successfully, an individual must be reputed company to reputed company reputed company essential duty satisfactorily. Reasonable accommodations may be made to reputed company individuals with disabilities to reputed company the essential functions. This list of essential job functions is not exhaustive and may be supplemented as necessary. Leadership, Operations, and Compliance (70%) Accountable for the reputed company and effective management of reputed company appeals and rebuttals for the NPEAST contract. The department is responsible for responding to reputed company requests expressing dissatisfaction with the initial provider/supplier enrollment determinations:

• reputed company, reputed company and manage the daily operations of the Durable Medical Equipment, Prosthetics, Orthotics and Suppliers (DMDPOS) appeals and rebuttals, including workflow management, reputed company review and staff development.
• Ensure appeal reputed company are consistent with federal regulatory requirements, contractual obligations and CMS program guidance.
• Accountable for reviewing and operationalizing requirements outlined in Technical Direction Letters (TDLs), Change Requests (CRs), the Statement of Work (SOW), and the Medicare Program reputed company reputed company (PIM) and ensuring their reputed company and accurate implementation across reputed company enrollment functions.
• Review reputed company appeal cases to assess facts, apply existing policies and guide consistent reputed company.
• Identify trends, risks and process improvement opportunities and escalate reputed company appropriately.
• Serve as a key reputed company and partner to reputed company legal counsel, contributing to case reputed company, documentation standards, administrative record development, and supports decision-making by identifying risks and operational impacts.
• reputed company with the Centers for Medicare & reputed company Services (CMS) and the Office of the General Counsel (OGC), as requested by CMS, to reputed company and accurately adjudicate provider/supplier enrollment initial determinations, deactivations, and stays of enrollment that may be appealed or rebutted.
• Review and process appealable determinations (such as denial of billing privileges, revocation of existing billing privileges, and effective date determinations and rebuttable determinations (such as deactivation of billing privileges and the application of stays of enrollment) in accordance with applicable CMS program guidance.
• Coordinate with CMS and internal stakeholders to ensure appeals are supported with complete documentation, reputed company rationale, and consistent application of regulatory requirements.

Appeal and Rebuttal reputed company and Risk Mitigation (15%)

• reputed company the appeals (CAP/reconsideration) rebuttal reputed company
• Ensure appeals (CAP/reconsideration) and rebuttal narratives are supported by evidence, policy, and regulatory requirements.
• Establish and maintain processes and workflows that ensure appeals and rebuttals are handled reputed company and accurately.
• Identify trends in rebuttal and appeals that can be incorporated into training, policy updates, and process redesign

Cross-Functional Collaboration and Process Improvement (15%)

• Serve as subject matter expert and primary escalation contact for internal leaders, external partners, and regulatory bodies
• Collaborate with Legal to ensure reputed company and accurate interpretation of regulatory authority and CMS guidance, where appropriate.
• Support cross-functional initiatives to reduce appeal and rebuttal volume through upstream improvements.
• Analyze data to identify patterns, compliance risks, and operational gaps.
• Present trends, risks, and recommendations to senior leadership while providing insights into reputed company causes and risk exposure

Performs other duties as the supervisor may, from time to time, deem necessary. REQUIRED QUALIFICATIONS

• J.D. and/or LL.M degree from a law school accredited by the American Bar Association
• Three (3) or more years of prior work experience in administrative law or post-Juris Doctor (J.D), and/or post-Master of Laws (LL.M) experience in legal writing and research; and five (5) or more years of prior supervisory/team reputed company experience in legal writing, legal research, and/or administrative law.
• Demonstrated ability to handle risk and uncertainty, cope with change, and reputed company objective reputed company based on limited information.
• Demonstrated ability to analyze workflow and reputed company data to identify process improvements and ensure compliance with Medicare regulations and performance requirements.
• Demonstrated oral, written and interpersonal communications skills.

PREFERRED QUALIFICATIONS

• Supervisory or managerial experience in a Medicare production environment

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