Redetermination Examiner, Medicare, DME

Simsy Ventures

. Conduct redetermination reviews per Medicare rules and regulations .

Posted 10/31/2026contractRemote • United StatesJunior💰 $22 per hourWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in Medicare rules and regulations, ensuring accurate claims processing and compliance with CMS standards. Proficient in communication, problem-solving, and training to enhance operational efficiency and reduce redeterminations.

Highest-signal resume keywords

Medicare Rules ComplianceClaims Processing EvaluationAnalytical SkillsCommunication SkillsTraining and Education Facilitation

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Claims ProcessingDocumentation EvaluationRedetermination ReviewsOverpayment Appeals ProcessingProofreadingResearch SkillsCMS ComplianceGuideline WritingGeneral PC Knowledge

Soft Skills

Strong PrioritizationAdaptabilityProfessional CommunicationProblem-Solving

Certifications & Qualifications

High School DiplomaGED

Industry Keywords

CMS RequirementsJoint Operating AgreementAppeals ProcessEducational ReferralsProcessing Guidelines

About the role

Key responsibilities & impact

Conduct redetermination reviews per Medicare rules and regulations
Respond to incoming appeals from Medicare appellants professionally, timely, and accurately
Write and proofread letters according to current guidelines
Research and identify claims processing deficiencies and initiate corrective responses
Evaluate documentation and history against policy criteria for accurate, CMS-compliant processing
Submit educational referrals as necessary to decrease redeterminations and allow claims to pay at the lowest level of appeal
Assist in writing and updating processing guidelines
Identify internal/external education and training needs, communicate findings, and assist in training as needed
Communicate information to appropriate internal and external parties
Problem-solve and research effectively
Process overpayment appeals as needed
Maintain up-to-date knowledge of working systems, processing instructions, and relevant resources
Maintain knowledge of CMS and Joint Operating Agreement requirements

Requirements

What you’ll need

High School Diploma or GED
6 months’ work-related experience
General PC knowledge
Strong prioritization, analytical and communication skills
Ability to adapt to changes
Candidates must live in and work from an eligible U.S. state when they are hired and for as long as they are employed
Broadway Ventures conducts background checks and drug testing prior to the start of employment
Some positions may also require fingerprinting

Benefits

Comp & perks

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
Training will be provided