Medicare Appeals Paralegal

Description

The Medicare Appeals Paralegal serves as a subject matter expert supporting the Firm's healthcare reimbursement and litigation practice by managing complex Medicare cost report appeals, reimbursement analyses, and related litigation matters. The Medicare Appeals Paralegal independently manages routine case actions for the appeals, analyzes highly technical reimbursement issues, develops strategic recommendations, and coordinates with clients, regulatory agencies, and litigation teams to ensure successful case outcomes.

Key Roles and Responsibilities:

Medicare Reimbursement Analysis

• Assist with the technical management of Medicare Cost Report group and individual appeal matters
• Continually collaborate with attorneys regarding filing requirements, procedural deadlines, and regulatory compliance obligations to ensure timely submissions
• Analyze Medicare cost reports, reimbursement calculations/trends, payment methodologies, regulatory developments and supporting financial data
• Calculate and validate Amounts in Controversy (AIC) and other reimbursement metrics required for appeals
• Identify and communicate procedural issues, risks, and opportunities that may impact appeal outcomes and recommend appropriate actions
• Perform financial modeling and cost-benefit analyses to evaluate appeal viability and potential recovery opportunities
• Develop recommendations regarding appeal participation and reimbursement recovery opportunities

Documentation & Reporting

• Collect, organize, and analyze complex financial, operational, and reimbursement documentation supporting appeals
• Prepare, draft, review, and maintain appeal filings, exhibits, reports, and supporting materials, ensuring accuracy, completeness, and consistency
• Maintain internal databases, reimbursement tracking tools, and reporting systems
• Prepare recurring reports related to appeal activity, recoveries, and cost-sharing obligations

Client & Stakeholder Relationship Management

• Serve as a point of contact for clients regarding appeal status, reimbursement analyses, strategic considerations and procedural matters
• Communicate directly with attorneys, healthcare providers, Medicare Administrative Contractors (MACs), PRRB personnel, and other stakeholders
• Facilitate resolution of technical, financial, and regulatory issues affecting appeal matters

Primary Competencies:

• Ability to effectively communicate complex details to clients and stakeholders
• Excellent writing, grammar and proofreading skills
• Ability to work independently to find solutions to technical problems
• Detail-oriented with strong organizational and time management skills
• Ability to make recommendations and/or decisions in a fast-moving environment

Knowledge, Skills, Experience & Education:

• Knowledge of Medicare reimbursement principles, Medicare Cost Reports, PRRB appeals, and healthcare regulatory requirements
• Strong analytical skills with the ability to interpret complex reimbursement data
• Ability to exercise independent judgment and develop recommendations based on technical analysis and regulatory interpretation
• Proficiency with Microsoft Excel, databases, and case management system.
• Experience working with healthcare providers, reimbursement consultants, regulatory agencies, or healthcare litigation teams preferred
• Paralegal Certificate + five year experience preferred, but commensurate education and experience is also considered.

Travel and Physical Requirements:

• Limited travel
• Prolonged periods of sitting at a desk and working on a computer
• Frequent use of hands and fingers for typing, writing, and operating office equipment
• Occasional standing, walking, bending, and reaching
• Ability to lift and carry up to 10-15 pounds (e.g., files, documents, office supplies)
• Visual acuity to read screens, review documents, and analyze detailed information
• Ability to communicate effectively via phone, video, and in person

NOTE: This job description covers essential job duties and requirements is not intended to be all-inclusive. Employee may perform other related duties as required to meet the ongoing needs of the Firm.