Dispute Resolution Reviewer (Healthcare Professional)

Dispute Resolution Reviewer III (Healthcare Professional)

Role Overview

This position involves reviewing medical records and documentation from patients, beneficiaries, or providers to resolve disputes or appeals. The reviewer makes independent, impartial decisions based on medical evidence, laws, regulations, and policies, ensuring fair and accurate resolution of issues.

Key Responsibilities

• Evaluate case files and medical records to write clear, concise dispute resolutions supporting determinations.
• Respond to all appeal issues raised by stakeholders, ensuring thorough and fair consideration.
• Conduct research using federal regulations, medical literature, and policy manuals to inform decisions.
• Stay updated on changes in healthcare regulations, practices, and policies.
  
  

Qualifications & Skills

• Associate's degree or 60+ credit hours toward a Bachelor's in healthcare or related field; experience may substitute for education.
• At least 3 years of experience in medical dispute resolution, Medicare appeals, or related healthcare roles.
• Healthcare professional background in nursing, physical therapy, respiratory therapy, or occupational therapy; law or advanced degrees may substitute experience.
• Experience in writing appeal or payment determinations; independent dispute resolution experience preferred.
• Ability to make sound decisions based on evidence, regulations, and policies.
  
  

Additional Details

• Remote work within the United States.
• Includes benefits such as health insurance, 401K, tuition reimbursement, and credentialing support.
  
  

This role emphasizes fair, evidence-based dispute resolution with a focus on healthcare knowledge and regulatory compliance.