Remote Reconsideration Analyst III - Appeals & Research

TMF Health Quality Institute; United States; Hybrid; USD 42,000 - 60,000; Full time

Benefits offered by this job

Medical insurance

Dental insurance

Vision insurance

Life insurance

AD&D insurance

Short-term disability

Long-term disability

Section 125 plan

401K

Tuition Reimbursement

Job summary

TMF Health Quality Institute is seeking a remote, second-level non-medical appeals specialist to render fair, well-supported decisions for beneficiaries, suppliers, and providers. You will review evidence, apply regulations, and ensure privacy and proper release of documents.

The role involves researching federal regulations, policy materials, and payer guidelines, with emphasis on clear writing, accurate overpayment calculations, and handling a high-volume of cases from a nationwide network.

Qualifications

• Three (3) years of general office experience.
• Two (2) years high volume of customer calls, appeals, or billing.
• Resided in the United States for a minimum of three (3) years out of the last five (5) years (Per Contract Requirement)

Responsibilities

• Writes a reconsideration decision that is clear and supports the determination made.
• Ensures that all appeal issues raised by the beneficiary, representative, supplier, and/or provider have been addressed.
• Provides a fair and impartial decision based on current evidence, regulations, policies, and procedures.
• Ensures all documents are releasable and do not violate any Privacy Act provisions.
• Organizes documents by dates of service relevant to the charges, research denials and regulations used and ensure that any overpayment calculation is correct.
• Conducts research using online federal regulations, contract policy, standards of medical practice, contractor manuals, coverage manuals, and other related resources to complete an accurate and well-supported decision.

Skills

General office experience

Customer service

Billing knowledge

Education

High School Diploma or equivalent

Job description

TMF Health Quality Institute is seeking a remote, second-level non-medical appeals specialist to render fair, well-supported decisions for beneficiaries, suppliers, and providers. You will review evidence, apply regulations, and ensure privacy and proper release of documents.

The role involves researching federal regulations, policy materials, and payer guidelines, with emphasis on clear writing, accurate overpayment calculations, and handling a high-volume of cases from a nationwide network.