Dispute Resolution Reviewer I

St. George Tanaq Corporation; Raleigh (NC); Remote; USD 50,000 - 65,000; Full time

Job summary

A leading company is seeking a Dispute Resolution Reviewer I to support federal clients by reviewing medical records and making independent decisions on appeals. This remote position requires expertise in Medicare appeals and healthcare compliance. The role involves thorough documentation and adherence to regulations, ensuring fair outcomes for beneficiaries. Candidates must have at least one year of relevant experience and an Associate’s degree or equivalent education.

Qualifications

• One year of experience in Medicare appeals or healthcare compliance.
• Knowledge of HIPPAA regulations and PII.

Responsibilities

• Reviews medical records and writes clear, impartial decisions.
• Conducts research using federal regulations and medical literature.
• Ensures all beneficiary issues are addressed.

Skills

Medicare appeals

Healthcare compliance

Regulatory interpretation

HIPPAA regulations

Education

Associate’s degree

Tools

Microsoft 365

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 Dispute Resolution Reviewer I (DRR I) to support a contract with our federal client. The Dispute Resolution Reviewer I will perform complex (journey-level) work and provide dissatisfied beneficiaries and / or providers the opportunity to present documentation or evidence to demonstrate why an appeal or rebuttal for an enrollment denial, revocation, or suspension should be allowed.

The DDR I will also provide an independent second-level determination based on the documentation, facts, laws, regulations, and guidelines. This role will work under general supervision, with moderate latitude for 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 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, regulation, rulings, and policy

Responds to and ensures that all issues raised by the beneficiary, representative, supplier, and provider 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 special projects and performs other duties as assigned

Requirements

Required Experience and Skills

One (1) year of Medicare appeals, medical review, clinical, healthcare regulatory interpretation / application, healthcare compliance or related experience in a healthcare setting

Knowledge and experience following HIPPAA regulations and personal identifiable information (PII).

Experience using Microsoft 365, including Excel and Word.

Experience in Appeals and billing, preferred

Coding certificate preferred

Ability to obtain a government clearance.

Must be able to pass Federal and state criminal background checks, as required by client.

Must be able to pass a drug screen, as required by the client.

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.

Our Commitment to Non-Discrimination

Tanaq Support Services 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.

If you are an individual with a disability and need assistance completing any part of the application process, please email [emailprotected] to request a reasonable accommodation. This email is for accommodation requests only and cannot be used to inquire about the status of applications.

Notice on Candidate AI Usage

Tanaq is committed to ensuring a fair and competitive interview process for all candidates based on their experience, skills and education. To ensure the integrity of the interview process, the use of artificial intelligence (AI) tools to generate or assist with responses during phone, in person and virtual interviews is not allowed. However, candidates who require a reasonable accommodation that may involve AI are required to contact us prior to their interview at [emailprotected] .

To view the Dispute Resolution Reviewer I and all our job postings, visit us at :

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Dispute Resolution • Raleigh, NC, United States