Claims Rep II – GHA Redetermination Rep
- Role
- Support
- Employment
- Full-time
Open to US, GE only. Set where you work from to check your eligibility.
No BS summary
Medicare claims adjudicator for first-level redeterminations who can apply Medicare regulations and process claims accurately. Remote in the listed US states and must meet CMS residency requirement (lived in US 3 of last 5 years). Requires comfort with multiple systems, letter writing, and production/quality-driven work.
Core skills
Required skills
At Broadway Ventures , we transform challenges into opportunities with expert program management, cutting-edge technology, and innovative consulting solutions. As an 8(a), HUBZone, and Service-Disabled Veteran-Owned Small Business (SDVOSB), we empower government and private sector clients by delivering tailored solutions that drive operational success, sustainability, and growth. Built on integrity, collaboration, and excellence, we’re more than a service provider—we’re your trusted partner in innovation. Total comp value: $22/hr Respond to requests for first-level appeals. Review and compare processed claims with edit/audit detail and Medicare Policy. Refer case to appeal nurse for medical necessity determination. Review medical documentation and claims history for frequency of service, required coding elements, and accurate fee determinations. Complete decision letters or claim adjustments as required to effectuate first level of appeal decisions. Establish and maintain a professional rapport with contacts and present a favorable corporate image. Additional Information: Start Date: Tuesday, September 22, 2026 Training Schedule: (4 Weeks): Monday through Friday, 7:30am-4:05pm CST Work Location This role is open to remote work for this opportunity in the following approved states: Florida, Georgia, Illinois, Indiana, Iowa, Michigan, Minnesota, Missouri, Nebraska, North Carolina, South Carolina, Texas, Wisconsin In this role you will: Receive, review, and provide written responses (Medicare Redetermination Notice [MRN]) to requests from customers on a post-claim basis in first step of Medicare appeal process. Apply knowledge of Medicare regulations, claims processing, and appeal guidelines to determine proper resolution of requests. Obtain and review system and hard copy documentation and medical notes. Review and compare processed claims for required coding elements to establish medical necessity, frequency of service, and accurate fee determinations. Refer cases to appeal nurses when clinical judgment is required to make decision or is required by audit. Determine appropriate resolution to appeal request and adjudicate redetermination decision by resolving all error edits and audits, changing codes, entering allowable amounts, working with other units, pending requests for development, and adjudicating claim to completion. Determine appropriate financial liability for decision. Develop and complete explanations of decision for MRN decision letter through use of various letter templates, policy information, and input from medical staff. Use various technological applications, such as Word, web portal, or electronic letter writing system to generate and revise determination notifications. Resolve pended/aged cases, log all requests, and document/update clearly on-line comment file with detail of action taken. Research electronic redetermination work processes and reference manuals throughout process of making determinations regarding requests. Correspond with Medicare customers to clarify information for claim determination and explain claim adjudication. Assist and educate providers on Medicare regulations by utilizing CMS guidelines, publications, and reference materials to ensure correct claim submission. Refer recurrent provider errors to Provider Education for further contact. Identify, verify, calculate, and setup overpayment situations. Assist in reporting and recoupment of overpayments. Identify and refer potential fraudulent providers and/or beneficiaries to Complaint Screening. Refer and forward mis-directed correspondence and unusual claims aberrancies to appropriate area for handling. Assist department in meeting CMS performance metrics and minimum quality and quantity standards. Provide back-up for completing staff responsibilities as needed. Provide technical assistance by identifying and reporting system problems, testing new enhancements, and other changes as released. How do I know this opportunity is right for me? If you: Are interested in learning and applying Medicare guidelines and computer-based tools Have knowledge of or ability to learn and apply insurance and medical terminology Have knowledge of Medicare, navigating multiple systems and letter writing. Enjoy identifying issues, researching, and initiating appropriate actions Enjoy a flexible work schedule What will I gain from this role? Enhanced learning of Medicare guidelines Experience being a part of a successful team that services providers and beneficiaries within the Medicare program. Knowledge from working within a supportive, high-performing and team-building environment Experience working in an environment that serves our Nation’s military, veterans, Guard and Reserves and Medicare beneficiaries Working in a continuous performance feedback environment. Minimum Qualifications Must have lived in the United States at least 3 out of the last 5 years - this is a CMS requirement. High School diploma or equivalent We also prefer: 2 or more years recent Medicare experience (customer service, claims processing, or medical billing) dealing with coverage and medical necessity determinations. Appeals knowledge is preferred. Experience with navigating multiple systems. Experience with being successful in a production and quality-based environment Experience with letter writing with attention to details and proficient grammar. This may include a brief telephone interview or email communication to verify resume details and discuss compensation expectations. Interviews will be conducted with the most qualified candidates. Broadway Ventures conducts background checks and drug testing prior to the start of employment. Some positions may also require fingerprinting. Broadway Ventures is an equal opportunity employer and a VEVRAA federal contractor. We do not discriminate against applicants or employees on the basis of race, color, religion, sex, national origin, age, disability, protected veteran status, or any other status protected by applicable law. Reasonable accommodations are available for applicants with disabilities. Broadway Ventures utilizes the OFCCP-approved Voluntary Self-Identification of Disability Form (CC-305). The pay range shown is a good-faith estimate of the compensation Broadway Ventures reasonably expects to pay for this position at the time of posting. It is not a guarantee of any particular wage, salary, or total compensation. Actual pay offered depends on job-related factors, which may include skills, experience, education, certifications and licensure, geographic work location, contract funding and budget. For positions covered by the Service Contract Act, pay is also governed by the applicable Department of Labor wage determination, which the government may revise. Some positions are posted in support of a contract proposal that has not yet been awarded. Where that is the case, the position and its final compensation are contingent upon award of the contract to Broadway Ventures and on the terms of the awarded contract, including any government-approved labor rates and the applicable wage determination. Broadway Ventures offers a comprehensive benefits package. A general description of benefits is below. 401(k) and company match PTO that grows the longer you stay Health, Vision, Dental Company provided Life Insurance and Voluntary Life Insurance Short Term Disability and Long Term Disability
What you'll do
- Receive, review, and provide written responses (Medicare Redetermination Notice [MRN]) to requests for first-step Medicare appeals.
- Apply knowledge of Medicare regulations, claims processing, and appeal guidelines to determine proper resolution of requests.
- Obtain and review system and hard copy documentation and medical notes.
- Review and compare processed claims for required coding elements to establish medical necessity, frequency of service, and accurate fee determinations.
- Refer cases to appeal nurses when clinical judgment is required or required by audit.
- Adjudicate redetermination decisions by resolving error edits/audits, changing codes, entering allowable amounts, and working with other units to complete claims.
- Determine appropriate financial liability and identify/setup overpayment situations.
- Develop and complete explanations of decisions for MRN decision letters using templates, policy information, and medical staff input.
- Use Word, web portals, or electronic letter systems to generate and revise determination notifications.
- Resolve pended/aged cases, log requests, and document/update online comment files with details of actions taken.
- Correspond with Medicare customers and assist/educate providers using CMS guidelines and reference materials.
- Refer recurrent provider errors to Provider Education and potential fraud to Complaint Screening.
- Assist department in meeting CMS performance metrics and quality/quantity standards.
- Provide back-up for staff responsibilities and assist in testing/reporting system problems and enhancements.
What they require
- Must have lived in the United States at least 3 out of the last 5 years (CMS requirement).
- High School diploma or equivalent.
- Knowledge of or ability to learn and apply Medicare guidelines, claims processing, and medical terminology.
- Ability to navigate multiple systems and follow CMS guidelines and reference manuals.
- Experience with letter writing, attention to detail, and proficient grammar (preferred).
- Preferred: 2 or more years recent Medicare experience (customer service, claims processing, or medical billing) dealing with coverage and medical necessity determinations; appeals knowledge preferred.
- Ability to meet production and quality-based environment expectations.
- Remote Work Requirements: high speed cable or fiber internet with minimum 10 Mbps downstream and at least 1 Mbps upstream.
- Background checks, drug testing, and in some positions fingerprinting are required prior to start.
- Equal opportunity employer; reasonable accommodations available for applicants with disabilities.
Benefits
- 401(k) and company match
- PTO that grows with tenure
- Health, Vision, Dental insurance
- Company-provided Life Insurance and Voluntary Life Insurance
- Short Term Disability and Long Term Disability
Broadway Ventures transforms challenges into opportunities with expert program management, technology, and consulting solutions for government and private sector clients. It is an 8(a), HUBZone, and Service-Disabled Veteran-Owned Small Business (SDVOSB).