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. The candidates for this position MUST have an MSCC (Medicare Set-Aside Certified Consultant) and they MUST have knowledge of the WCR/MSA reference guide.

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. Medicare Set-aside Certified Consultant (MSCC) Medicare Set-aside (MSA) Centers for Medicare & Medicaid Services (CMS) Workers' Compensation Review Contractor (WCRC) MSP Compliance Medicare Secondary Payer (MSP) What You'll Do As a Determinations Specialist, you will: Review CMS determination letters and evaluate cases with and without disagreement regarding MSA recommendations. Identify, analyze, and communicate discrepancies between ECS and CMS recommendations. Conduct comprehensive research and gather supporting clinical and regulatory documentation to substantiate ECS MSA recommendations. Assess CMS findings and determine whether a case warrants reconsideration. Partner with clients to explain recommendations, provide supporting rationale, and determine next steps. Utilize your expertise in Medicare coverage policies and the WCMSA Reference Guide to support case evaluations and decision-making. Analyze and defend ECS recommendations, including complex prescription drug allocations. Build compelling, well-documented submissions and supporting materials for presentation to CMS. Maintain accurate and timely documentation within Galileo and other company systems. Ensure compliance with client protocols, departmental procedures, HIPAA requirements, and all applicable regulations. Contribute to a collaborative team environment while supporting additional projects and initiatives as assigned. Why Join ExamWorks? At ExamWorks, you'll work alongside industry experts in a highly specialized field where your knowledge and expertise directly influence outcomes for clients. This role offers the opportunity to tackle challenging cases, deepen your regulatory expertise, and contribute to a team dedicated to excellence, accuracy, and continuous improvement. If you're an experienced MSCC professional looking for a role that values critical thinking, attention to detail, and subject matter expertise, we encourage you to apply today.

QUALIFICATIONS

Previous Customer Service experience required. Minimum 12 months production environment experience or related experience preferred. Adequate knowledge of 3rd 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, religion, sex, sexual orientation, gender identity, national origin, age or any other status protected under local, state or federal laws. Equal Opportunity Employer - Minorities/Females/Disabled/Veterans