Perform evaluations of Medicare Fee-For-Service (FFS) Medicare Administrative Contractors (MACs) redeterminations; Medicare FFS, Part D and Part C Qualified Independent Contractors (QICs) operations and decisions; Medicare FFS, Part D and Part C Decision Letters, and Part C and Part D IRE database reviews, to determine the MAC and QIC adherence with their task order statement of work in accordance with CMS rules, regulations and policy guidance.

Responsibilities and Duties:

  • Attend Pre-Audit Training at the QICs that includes discussion of lessons learned, changes, common challenges and what to expect during the audit process
  • Perform on-site and/or remote evaluations not less than one business week in length at each of the FFS, Part C and Part D QICs
  • Perform remote audits of the FFS MACs redetermination case files
  • Evaluate the QIC reconsideration decisions to determine quality, accuracy, consistency and timeliness
  • Evaluate the MAC redetermination decisions to determine quality, accuracy and consistency
  • Verify an adequate rationale for the decision is provided by the QIC and MAC
  • Evaluate all types of cases within the IRE databases based on requirements within the Part C and Part D QIC’s SOW task orders, as well as any additional requirements supplied by CMS for consistency, accuracy and timeliness
  • Attend required meetings and workgroups as needed to discuss procedural changes, share trends, review information on specific case files, and discuss issues or questions
  • Utilize encrypted storage devices (e.g., CDs, flash drive, networks) that contain case file documentation
  • Utilize a modular application tool to document detailed evaluation finding
  • Meet productivity and quality assurance standards


  • Bachelor’s Degree or equivalent, related work experience
  • Two (2) or more years of Medicare Appeals experience
  • Quality assurance experience
  • Commitment to excellence and high standards
  • Excellent written and oral communication skills
  • Ability to work with all levels of management
  • Strong organizational, problem-solving and analytical skills
  • Ability to manage priorities and workflow
  • Versatility, flexibility, and willingness to work within constantly changing priorities
  • Acute attention to detail
  • Proven ability to handle multiple projects and meet deadlines
  • Good judgment with the ability to make timely and sound decisions
  • Creative, flexible, and innovative team player
  • Proficient with Microsoft Office Suite such as SharePoint, Teams, Outlook, Word, and Excel
  • A minimum of 10% travel may be required on the East Coast


Please click here if you are interested in this open position (attach resume to email if applicable).

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NHA is an equal opportunity/equal access employer fully committed to achieving a diverse workforce. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or veteran status, or any other protected class