Dispute Resolution Reviewer I (Non - Healthcare Professional)

TMF Health Quality Institute; Austin (TX); Remote; USD 55,000 - 75,000; Full time

Job summary

A leading healthcare organization is seeking a detail-oriented professional to perform complex work related to Medicare appeals. The role involves reviewing medical records, making independent decisions, and ensuring fair outcomes for beneficiaries. Ideal candidates will have an Associate's degree and experience in healthcare compliance or medical review. This remote position offers a comprehensive benefits package, including medical, dental, and 401K options.

Benefits

Medical, dental, vision insurance

401K

Tuition Reimbursement

Qualifications

• One year of Medicare appeals or related experience required.
• Additional experience may substitute for education.

Responsibilities

• Reviews medical records and writes clear, impartial decisions.
• Makes independent decisions based on medical evidence.
• Addresses all issues raised by beneficiaries and providers.

Skills

Healthcare Compliance

Medical Review

Decision Making

Education

Associate's degree

60 credit hours towards Bachelor's degree

Job description

Please make sure your application is complete, including your education, employment history, and any other applicable sections. Initial screening is based on the minimum requirements as defined in the job posting, such as education, experience, licenses, and certifications. Your experience should also address the knowledge, skills and abilities needed for the role. Incomplete applications will not be considered.

• This position is located Remote Anywhere US

Position Purpose :

Performs complex (journey-level) work. Provides 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. 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.

• 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.

Minimum Qualifications

Education

• 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.)

Experience

• One (1) year of Medicare appeals, medical review, clinical, healthcare regulatory interpretation / application, healthcare compliance or related experience in a healthcare setting
• Appeals and Billing, preferred
• Coding Certificate, preferred

C2C offers an excellent benefits package, including :

• Medical, dental, vision, life, accidental death and dismemberment, and short and long-term disability insurance
• Section 125 plan
• 401K
• Tuition Reimbursement

EOE Vet / Disability

Equal Opportunity Employer / Protected Veterans / Individuals with Disabilities

This employer is required to notify all applicants of their rights pursuant to federal employment laws. For further information, please review the Know Your Rights notice from the Department of Labor.