Medicare Set Aside Allocator/Panel Nurse

J29 Overview:

J29, Inc. has been supporting commercial, State, and Federal health and human service programs since company inception in 2017. Our team of 240 employees focuses on providing claim, policy, and clinical analysis on the end-to-end of medical cases, claims, disputes, appeals, and audits. Our team is experienced in program, payment, provider, and patient integrity as we continue to support advanced programs of policy, clinical requirements, and compliance measures at the commercial, State, and Federal levels.

J29 was founded to be an employee-centric company that prioritizes the well-being and value of its employees. Our mission is to empower our employees to do great things for the benefit of those that needs us most. The J29 mission supports not only our health and human service programs, but also the philanthropy efforts of our team. We are proud to continue our support to non-profit groups with critical missions as J29 continues to grow

Job Description:

The position of Medicare Set Aside Allocator/Panel Nurse at J29, Inc. is a critical role primarily responsible for the allocation of Medicare Set-Asides (MSAs), Medical Cost Projections (MCPs), and Life Care Plans (LCPs) to support our rapidly expanding Medicare Secondary Payer (MSP) compliance division.. Additionally, this role will involve participation in J29’s Independent Dispute Resolution (IDR) team, which entails the review of healthcare claims. This full-time position may require additional off-business hours as needed to fulfill the responsibilities effectively.

Key Responsibilities:

• Allocate Medicare Set-Asides (MSAs), Medical Cost Projections (MCPs), and Life Care Plans (LCPs) to ensure compliance with Medicare Secondary Payer (MSP) regulations and guidelines.
• Utilize expert-level knowledge of software tools and relevant compendia related to pricing/allocating in MSAs, MCPs, and LCPs
• Identify and mitigate healthcare and pharmacy cost drivers in MSAs
• Apply extensive medical knowledge and experience with medical terminology, ICD-9/10 Codes, Current Procedure Terminology Codes (CPT) codes, and workers’ compensation fee schedules in pricing medical items and services
• Ensure compliance with Healthcare Common Procedure Coding System (HCPCS) coding practices, Medicare coverage guidelines, anatomy, physiology, pharmacology, clinical practice guidelines, utilization review standards and practices, state-specific workers’ compensation guidelines and pricing structure, and Health Insurance Portability and Accountability Act (HIPAA) and related healthcare confidentiality regulations.
• Breaking into places we're not working in yet

Required Qualifications:

• A bachelor’s degree from an accredited college or university in Nursing
• At least 5 years of related experience
• Medicare Set-Aside Certified Consultant (MSCC) certification
• Preferred: Certified Life Care Planner (CLCP) designation
• U.S. Citizenship with the ability to obtain a Government Clearance
• Substantial medical knowledge and experience with medical terminology, ICD-9/10 Codes, Current Procedure Terminology Codes (CPT) codes, and exposure to applying actual costs and workers’ compensation fee schedules in pricing medical items and services
• Prior experience in identifying/mitigating healthcare and pharmacy cost drivers in MSAs
• Preferred: Prior Utilization Review/Nurse Case Management experience
• Extensive Medicare Set-Aside (MSA) allocation experience, along with allocation of Medical Cost Projections (MCPs) and Life Care Plans (LCPs)
• Expert-level knowledge of software tools and relevant compendia related to pricing/allocating in MSAs, MCPs, and LCPs
• Additional Knowledge of Healthcare Common Procedure Coding System (HCPCS) coding practices, Medicare coverage guidelines, anatomy, physiology, pharmacology, clinical practice guidelines, utilization review standards and practices, state-specific workers’ compensation guidelines and pricing structure, and Health Insurance Portability and Accountability Act (HIPAA) and related healthcare confidentiality regulations.

J29, Inc. is committed to hiring and retaining a diverse workforce. We are proud to be an Equal Opportunity/Affirmative Action Employer, making decisions without regard to race, color, religion, creed, sex, sexual orientation, gender identity, marital status, national origin, age, veteran status, disability, or any other protected class. J29, Inc. is a proud Veteran friendly employer.