Dispute Resolution Reviewer III

Shelby American, Inc.; Anchorage (AK); Remote; USD 75,000 - 95,000; Full time

Job summary

A leading company is seeking a Dispute Resolution Reviewer III to support federal clients by resolving disputes and making determinations based on medical evidence. This remote role requires strong clinical experience and the ability to write clear decisions. Ideal candidates will have a background in healthcare and experience in dispute resolution, ensuring fair outcomes for patients and providers.

Qualifications

• 2-3 years of experience in medical dispute resolution or Medicare appeals.
• Healthcare professional with Nursing, Physical Therapy, or Occupational Therapy experience.
• Demonstrated experience writing appeal or payment determinations.

Responsibilities

• Reviews medical records and writes clear, concise dispute resolution decisions.
• Makes independent decisions based on medical evidence and regulations.
• Conducts research to support accurate decision-making.

Skills

Medical Dispute Resolution

Clinical Experience

Patient-Provider Dispute Resolution

Writing Determinations

Education

Associate’s Degree in Healthcare

Bachelor’s Degree in Related Discipline

Tools

Office 365

Excel

Word

Job description

All Jobs > Dispute Resolution Reviewer III

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 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

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
• 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.

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 [e-mail] 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 [e-mail].