Clinical Appeals Reviewer

Tanaq Health; United States; On-site; USD 70,000 - 90,000; Full time

Job summary

Tanaq Health is seeking a Clinical Appeals Reviewer for a remote position anywhere in the United States. The role involves reviewing medical records, making independent decisions on appeal cases, and requires licensed healthcare professionals such as RNs or PTs. Candidates should have three years of experience in medical dispute resolution and possess effective research and communication skills. Responsibilities include writing decision letters and staying updated on regulations. Tanaq Health values diversity and is committed to equal employment opportunities.

Qualifications

• Three years of experience in medical dispute resolution or related healthcare roles.
• Licensed professional in Nursing, Physical Therapy, Respiratory Therapy, or Occupational Therapy.
• Ability to analyze and interpret policies, including Medicare regulations.

Responsibilities

• Review case files and write decision letters that support determinations.
• Make decisions based on medical evidence and regulatory compliance.
• Conduct thorough research on medical literature and regulations.

Skills

Medical dispute resolution

Communication skills

Research techniques

Clinical judgment

Problem-solving

Education

Associate's degree in healthcare

Job description

Tanaq Support Services (TSS) delivers professional, scientific, and technical services and information technology (IT) solutions to federal agencies in health, agriculture, technology, and other government services. TSS is a subsidiary of the St. George Tanaq Corporation, an Alaskan Native Corporation (ANC) committed to serving Federal customers while also giving back to the Tanaq native community and shareholders.

About the Role

We are seeking a Clinical Appeals Reviewer to support a contract with our federal client. The Clinical Appeals Professional performs complex (senior-level) work. Provides dissatisfied parties with the opportunity to present documentation to demonstrate why an appeal should be allowed. Provides an independent second level determination based on the documentation, facts, laws, regulations, and guidelines. Works under general supervision, with moderate latitude for the use of initiative and independent judgment. Qualified candidates must be licensed health care professionals capable of rendering independent clinical judgment, including but not limited to Registered Nurses (RN), Physical Therapists (PT), Occupational Therapists (OT), and Respiratory Therapists (RT).

This is a remote position that can be based anywhere in the United States. Must be able to work on a rotating schedule on weekends and holidays.

Responsibilities

• Reviews medical records/case files, writes reconsideration decision letters that are clear, concise, and impartial, and support the determination made, and documents the review.
• Makes sound, independent decisions based on medical evidence in accordance with statutes, regulations, rulings, and policy.
• Responds to and ensures that all appeal 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 management's direction.
• 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

Required Skills and Experience

• Three (3) years of experience in medical dispute resolution, Medicare appeals, medical review, clinical work, or related healthcare roles.
• Healthcare Professional with experience in Nursing, Physical Therapy, Respiratory Therapy, or Occupational Therapy experience.
• Demonstrated experience writing or making medical necessity decisions.
• Proficiency in research techniques, medical terminology, and analyzing and interpreting policies, along with knowledge of state and federal laws and regulations.
• Must have experience and working knowledge of the Medicare program, including coverage and payment rules.
• Experience with Medicare regulations, claims processing, and the medical review process, as well as applicable laws, rules, and regulations.
• Prioritize and organize work tasks to handle multitasking and meet deadlines.
• Ability to prepare correspondence and documents using correct spelling, grammar, and punctuation; proofreading and reviewing documents for clarity and consistency.
• Practice logic and reasoning to identify problems, verify facts, and reach valid conclusions.
• Experience in making decisions that support business objectives and goals.
• Ability to identify and resolve problems or refer issues appropriately.
• Communicate effectively verbally and in writing.
• Adapt to the needs of internal and external customers.
• Show integrity and ethical behavior, respect confidentiality, business ethics, and organizational standards.
• Ensure compliance with company policies, procedures, and guidelines, including cybersecurity, regulatory, contractual, and accreditation entities.
• Experience directly relevant to Medicare managed care appeals or utilization management activities, preferred.
• Must have resided in the United States for a minimum of three (3) years out of the last five (5) years. This is a contractual requirement.
• Must possess a valid driver\'s license with a clear and satisfactory driving record.
• Ability to obtain and maintain public trust clearance and customer approval.
• Must be legally authorized to work in the United States without the need for employer sponsorship, now or at any time in the future.

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 an 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 and Work Environment

• Requires working in an office/cubicle environment; sitting, standing, walking, bending, twisting, and/or reaching.
• Prolonged periods of sitting at a desk and working on a computer. May need to lift 25 pounds occasionally.
• May require the ability to operate a motor vehicle and travel by motor vehicle and commercial airline. May require overnight travel. Travel may be less than 5% annually.

Who We Are

Tanaq Support Services (TMS) 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.

Our Commitment to Non-Discrimination

Tanaq is an Equal Employment Opportunity Employer. All qualified applicants will receive consideration for employment without regard to disability, status as a protected veteran or any other status protected by applicable federal, state, or local law. Tanaq complies with the Drug-free Workplace Act of 1988 and E-Verify.