Dispute Resolution Reviewer III (Healthcare Professional, JD, or Masters Healthcare)

TMF Health Quality Institute; Austin (TX); Remote; USD 50,000 - 90,000; Full time

Job summary

An established industry player is seeking a dedicated professional to provide independent dispute resolutions for dissatisfied patients and providers. This remote role requires expertise in medical dispute resolution, Medicare appeals, and clinical experience. You will review medical records, conduct thorough research, and ensure fair decisions based on current regulations and policies. The position offers an excellent benefits package, including medical, dental, vision, and a 401K plan, making it an attractive opportunity for those passionate about healthcare and patient advocacy.

Benefits

Medical insurance

Dental insurance

Vision insurance

401K

Tuition Reimbursement

Life insurance

Disability insurance

Qualifications

• Three years of experience in medical dispute resolution or Medicare appeals.
• Experience in healthcare settings with a focus on patient-provider dispute resolution.

Responsibilities

• Review medical records and write impartial dispute resolution decisions.
• Conduct research to support decisions based on regulations and medical evidence.

Skills

Medical dispute resolution

Medicare appeals

Clinical experience

Research skills

Writing skills

Education

Associate's degree in healthcare

Bachelor's degree in healthcare

Juris Doctorate or Master's in Healthcare

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 :

Provides dissatisfied patients / beneficiaries and / or providers the opportunity to present documentation to demonstrate why an appeal / dispute should be allowed. Provides an independent second level determination / dispute resolution based on the documentation, facts, laws, regulations, and guidelines.

• 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, regulation, 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.

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

• Three (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 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

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.