Clinical Adjudication Supervisor

Job Summary

Providing oversight for Medicare appeals and dispute resolutions, the full-time Clinical Adjudication Supervisor will manage independent determinations based on medical evidence and documentation while working remotely and requiring weekend and holiday availability.

Key responsibilities

• Oversees formal discussions with appellants and providers to gather additional documentation and information regarding appeals
• Reviews medical records and case files, writing clear and impartial reconsiderations that support decisions made
• Makes independent decisions based on medical evidence in compliance with relevant statutes and regulations

Required qualifications

• Associate's degree or 60 credit hours towards a Bachelor's degree in healthcare or a related discipline
• Five years of experience in Medicare appeals, medical review, or utilization management of Medicare claims
• Supervisory or team lead experience in a healthcare setting
• Experience in writing or overseeing Medicare-related medical necessity decisions
• Background in Nursing, Physical Therapy, Respiratory Therapy, or Occupational Therapy is preferred