M&R Appeals Coder

Job Description

Function Asks:

• We are seeking dedicated and detail-oriented specialists who possess a coding certificate and have a strong understanding of records review. They will be responsible for handling appeals for Medicare members, specifically working on NCD/LCD denials, Duplicate denials, and MUE denials. The role involves reviewing medical records, comparing findings to CMS guidelines, and determining if conditions of coverage exist. If conditions are not met, the specialist will provide an uphold justification.

Volumes:

• 300 cases per week

FTEs:

• 1 domestic resources

Key Responsibilities:

• Review and analyze medical records for Medicare appeals.

• Work on NCD/LCD denials, Duplicate denials, and MUE denials.

• Compare medical findings to CMS guidelines.

• Determine if conditions of coverage are met.

• Provide uphold justifications when conditions of coverage are not met.

• Maintain accurate and detailed documentation of all reviews and decisions.

• Communicate effectively with team members and other stakeholders.

• Stay updated with CMS guidelines and changes in Medicare policies.

• Initially focus on FACETS cases, with plans to expand to COSMOS cases.

• Handle additional coding-related scenarios as the team expands.

Qualifications:

• Coding certificate (CPC, CCS, or equivalent).

• Strong understanding of medical records review.

• Experience with Medicare appeals and denials (NCD/LCD, Duplicate, MUE).

• Experience with FACETS (primary).

• Experience with COSMOS (secondary).

• Excellent analytical and problem-solving skills.

• Attention to detail and accuracy.

• Strong written and verbal communication skills.

• Ability to work independently and as part of a team.

• Familiarity with CMS guidelines and Medicare policies.

Preferred Qualifications:

• Previous experience in a similar role.

• Knowledge of healthcare regulations and compliance.