Full-Time
Claims Representative 2
GHA Redetermination Representative
Updated on 8/19/2026
Broadway Ventures
Compensation Overview
$22/hr
Iowa, USA + 12 more
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Remote
Category
 Administrative & Executive Assistance (1) |
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Required Skills
Medical Terminology
Word/Pages/Docs
Requirements
- Must have lived in the United States for at least 3 of the last 5 years to meet a Centers for Medicare & Medicaid Services requirement.
- Must have a high school diploma or equivalent.
- Must have high-speed cable or fiber internet with at least 10 Mbps downstream and 1 Mbps upstream.
- Must be able to learn and apply insurance and medical terminology.
- Must be able to learn and apply Medicare guidelines and computer-based tools.
Responsibilities
- Receive, review, and provide written Medicare Redetermination Notices to customers regarding post-claim requests in the first step of the Medicare appeals process.
- Apply Medicare regulations, claims processing knowledge, and appeal guidelines to determine the proper resolution of requests.
- Obtain and review system and hard-copy documentation and medical notes, and compare processed claims for coding elements, medical necessity, frequency of service, and fee determinations.
- Refer cases to appeal nurses when clinical judgment is required or an audit requires it.
- Adjudicate redetermination decisions by resolving edits and audits, changing codes, entering allowable amounts, coordinating with other units, pending requests for development, and completing claims adjudication.
- Determine the appropriate financial liability for each decision.
- Develop explanations of decisions for Medicare Redetermination Notice letters using templates, policy information, and medical staff input.
- Use Microsoft Word, web portals, and electronic letter-writing systems to generate and revise determination notifications.
- Resolve pending and aged cases, log requests, and clearly document actions in online comment files.
- Research electronic redetermination processes and reference manuals when making request determinations.
- Correspond with Medicare customers to clarify claim-determination information and explain claim adjudication.
- Assist and educate providers on Medicare regulations using Centers for Medicare & Medicaid Services guidelines, publications, and reference materials; refer recurring provider errors to Provider Education.
- Identify, verify, calculate, and set up overpayment situations, and assist with overpayment reporting and recoupment.
- Identify and refer potentially fraudulent providers or beneficiaries to Complaint Screening.
- Refer misdirected correspondence and unusual claim aberrancies to the appropriate area.
- Assist the department in meeting Centers for Medicare & Medicaid Services performance metrics and quality and quantity standards, and provide backup for staff responsibilities.
- Identify and report system problems, test new enhancements, and test other released changes.
Desired Qualifications
- Two or more years of recent Medicare experience in customer service, claims processing, or medical billing involving coverage and medical necessity determinations.
- Knowledge of Medicare appeals.
- Experience navigating multiple systems.
- Experience succeeding in a production- and quality-based environment.
- Experience writing letters with attention to detail and proficient grammar.