M&R Appeals Coder

Wipro Limited (NYSE: WIT, BSE: 507685, NSE: WIPRO) is a leading technology services and consulting company focused on building innovative solutions that address clients’ most complex digital transformation needs. Leveraging our holistic portfolio of capabilities in consulting, design, engineering, and operations, we help clients realize their boldest ambitions and build future-ready, sustainable businesses. With over 230,000 employees and business partners across 65 countries, we deliver on the promise of helping our customers, colleagues, and communities thrive in an ever-changing world.

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Function Asks:

• We are seeking dedicated and detail-oriented specialists who possess a coding certificate and have a strong understanding of records review. They will be responsible for handling appeals for Medicare members, specifically working on NCD/LCD denials, Duplicate denials, and MUE denials. The role involves reviewing medical records, comparing findings to CMS guidelines, and determining if conditions of coverage exist. If conditions are not met, the specialist will provide an uphold justification.

Volumes:

• 300 cases per week

FTEs:

• 1 domestic resources

Key Responsibilities:

• Review and analyze medical records for Medicare appeals.
• Work on NCD/LCD denials, Duplicate denials, and MUE denials.
• Compare medical findings to CMS guidelines.
• Determine if conditions of coverage are met.
• Provide uphold justifications when conditions of coverage are not met.
• Maintain accurate and detailed documentation of all reviews and decisions.
• Communicate effectively with team members and other stakeholders.
• Stay updated with CMS guidelines and changes in Medicare policies.
• Initially focus on FACETS cases, with plans to expand to COSMOS cases.
• Handle additional coding-related scenarios as the team expands.

Qualifications:

• Coding certificate (CPC, CCS, or equivalent).
• Strong understanding of medical records review.
• Experience with Medicare appeals and denials (NCD/LCD, Duplicate, MUE).
• Experience with FACETS (primary).
• Experience with COSMOS (secondary).
• Excellent analytical and problem-solving skills.
• Attention to detail and accuracy.
• Strong written and verbal communication skills.
• Ability to work independently and as part of a team.
• Familiarity with CMS guidelines and Medicare policies.

Preferred Qualifications:

• Previous experience in a similar role.
• Knowledge of healthcare regulations and compliance.

No
Performance Parameter
Measure 1 Process No. of cases resolved per day, compliance to process and quality standards, meeting process level SLAs, Pulse score, Customer feedback 2 Self
- Management Productivity, efficiency, absenteeism, Training Hours, No of technical training completed

Mandatory

Skills:

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The expected compensation for this role ranges from $24/hr to $25/hr .

Final compensation will depend on various factors, including your geographical location, minimum wage obligations, skills, and relevant experience.

Based on the position, the role is also eligible for Wipro's standard benefits

• full range of medical and dental benefits options
• disability insurance
• paid time off (inclusive of sick leave)
• other paid and unpaid leave options

Applicants are advised that employment in some roles may be conditioned on successful completion of a post-offer drug screening, subject to applicable state law.

Wipro provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state, or local laws. Applications from veterans and people with disabilities are explicitly welcome.

Wipro is committed to creating an accessible, supportive, and inclusive workplace. Reasonable accommodation will be provided to all applicants including persons with disabilities, throughout the recruitment and selection process. Accommodations must be communicated in advance of the application, where possible, and will be reviewed on an…