Determinations Specialist (32573)

**ExamWorks** is looking for a **Determinations Specialist** to join our team! The **Determinations Specialist** is responsible for utilizing clerical and clinical knowledge and applying critical thinking skills to review and evaluate files sent back from CMS with and without disagreement on MSA recommendations. This position analyzes CMS determination letters and identifies discrepancies, contacts clients, conducts research and ensures work is completed at the highest level and in compliance with all client protocols and departmental policies and procedures. **This is a Monday to Friday, 8am-5pm schedule.** **ESSENTIAL JOB FUNCTIONS** - Identify, analyze, and report discrepancies between ECS and CMS recommendations. - Research and provide reference information and physician support to substantiate ECS’s MSA recommendation where indicated. - Review of CMS findings; Identify if there is a basis to support reconsideration and contact clients to provide rationale and determine instructions to proceed. - Utilize knowledge of Medicare coverage guidelines and CMS published WCMSA Reference Guide; Navigate the computer database and conduct independent research as needed. - Research, analyze and defend the ECS MSA recommendations, including prescription drug recommendations. - Communicate effectively with the client and/or other authorized parties regarding supportive information required to support ECS’s position with the MSA. - Compose and attach all supporting documentation for presentation to CMS. - Enter all pertinent information into Galileo activities. - Observe and follow Client Protocols, which are posted on the Company Intranet. - Adhere to all departmental policies and procedures, including HIPAA requirements. - Adhere to all safety, health rules/regulations and security associated with this position and as directed by management. - Perform miscellaneous duties as assigned by management. **Education and/or Experience** - High school diploma or equivalent required. - Associate’s degree preferred. - Prior customer service experience required. - A minimum of twelve months MSA production environment experience or related experience is preferred. **QUALIFICATIONS** - Previous Customer Service experience required. Minimum 12 months production environment experience or related experience preferred. - Adequate knowledge of 3^rd^ party/COB (Coordination of Benefits) / insurance verification / medical billing (ICD-9/CPT) experience preferred. - Competency in mathematics, business terminology, clerical skills and time management. - Must possess complete knowledge of general computers, fax, copier, scanner, and telephone. - Must be knowledgeable of multiple software programs, including but not limited to Microsoft Word, Outlook, Excel, Adobe and the Internet. - Must have a full understanding of HIPAA regulations and compliance. - Ability to follow instructions and respond to managements’ directions accurately. - Demonstrates accuracy and thoroughness. Looks for ways to improve and promote quality and monitors own work to ensure quality is met. - Must demonstrate strong written and oral communication skills by conveying necessary information accurately, listening effectively and asking questions where clarification is needed. - Must be able to work independently, prioritize work activities and use time efficiently. - Must be able to maintain confidentiality. - Must be able to demonstrate and promote a positive team-oriented environment. - Must be able to stay focused and concentrate under normal or heavy distractions. - Must be able to work well under pressure and/or stressful conditions. - Must possess the ability to manage change, delays, or unexpected events appropriately. * * * ExamWorks, LLC is an Equal Opportunity Employer and affords equal opportunity to all qualified applicants for all positions without regard to protected veteran status, qualified individuals with disabilities and all individuals without regard to race, color,…