REQUIRED EXPERIENCE AND SKILLS

• Must have 2-3 years of medical dispute resolution or Medicare appeals, medical review, clinical, or related experience in a healthcare setting
• Healthcare Professional with Nursing, Physical Therapy, Respiratory Therapy or Occupational Therapy experience. Juris Doctorate (JD) or Master’s Degree in Healthcare or related discipline may be substituted for Healthcare Professional with Nursing, Physical Therapy, Respiratory Therapy or Occupational Therapy experience
• Demonstrated experience writing or making appeal or payment determinations
• Patient-Provider Dispute Resolution, preferred
• Independent Dispute Resolution, preferred
• Coding certificate, preferred
• Appeals and billing, preferred
• Experience using Office 365, including using Excel and Word
• Must be able to pass Federal and state criminal background checks, as required by client
• Must be able to pass drug screen, as required by client
• Ability to obtain a government clearance
• Must be legally authorized to work in the United States without the need for employer sponsorship, now or at any time in the future
• Experience working with/in the federal public health agency environment, preferred, but not required

EDUCATION AND TRAINING

• Associate’s degree or 60 or more credit hours towards a Bachelor’s degree from an accredited college or university in healthcare or related discipline. Additional experience in Medicare appeals, medical review, clinical, or other related experience in a healthcare setting may be substituted for Associate’s degree on a year per year basis (Experience requirements may be satisfied by full-time experience or the prorated part-time equivalent)

PHYSICAL REQUIREMENTS

• Prolonged periods of sitting at a desk and working on a computer. May need to lift 25 pounds occasionally.

WHO WE ARE

Tanaq Support Services (TSS) is a public health contractor, certified 8(a) business, owned by St. George Tanaq Corporation, an Alaska Native Corporation. (ANC). We listen to our stakeholders and leverage our science, technology, communication, and program expertise to understand and provide feedback as we develop solutions.

ABOUT THE ROLE

We are seeking a Dispute Resolution Reviewer III (DRR III) to support a contract with our federal client. The DRR III performs complex (senior-level) work. This role provides dissatisfied patients/ beneficiaries and/or providers the opportunity to present documentation to demonstrate why an appeal/dispute should be allowed. It also provides an independent second level determination/dispute resolution based on the documentation, facts, laws, regulations, and guidelines. The DRR III works under general supervision, with moderate latitude for the use of initiative and independent judgment.
This is a remote position that can be based anywhere in the United States.

RESPONSIBILITIES

• Reviews medical records/case file, writes a reconsideration/dispute resolution decision that is clear, concise, and impartial and supports the determination made, and documents review
• Makes sound, independent decisions based on medical evidence in accordance with statutes, regulations, rulings, and policy
• Responds to and ensures that all appeal/dispute issues raised by the beneficiary/patient, representative, and provider/supplier have been addressed
• Provides a fair and impartial decision based on current evidence, regulations, policies, and procedures
• Conducts research using online federal regulations, contract policy, standards of medical practice, contract manuals, coverage issues manuals, medical literature, and other related resources to complete an accurate and well-supported decision
• Stays abreast of changes in regulations, medical and healthcare practices, policies and procedures
• Participates in case specific verbal discussions
• Conducts reviews of appeals/disputes with multiple beneficiaries/services in one case
• Plans responses to statistical analysis challenges with assistance from statisticians
• Attends meetings and participates in workgroups at the direction of management
• Conducts quality reviews, as needed
• Serves as a subject matter expert
• Mentors and/or trains staff
• May conduct quality reviews and audits
• Participates in special projects and performs other duties as assigned
  Requirements: