Medicare Clinical Appeals Reviewer - Remote (RN, PT, OT, RT)

Apply Job Type Full-time Description Overview 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 Medicare Clinical Appeals Reviewer to support a contract with our federal client. The Appeals Professional III performs complex (senior-level) work. Provides dissatisfied parties with the opportunity to present documentation to demonstrate why an appeal should be allowed. Provides an independent second-level determination based on the documentation, facts, laws, regulations, and guidelines for Medicare Part C appeals. Works under general supervision, with moderate latitude for the use of initiative and independent judgment. While posted externally as a Medicare Clinical Appeals Reviewer III, this position is classified internally as an Appeals Professional III to meet contract requirements. This is a remote position. Candidates must be based in the United States and able to work Eastern, Central, or Mountain Time Zone business hours. Required: Active, unrestricted license in good standing as an RN, PT, RT, OT, or other qualifying licensed healthcare professional. Licenses with restrictions or encumbrances are not eligible. Responsibilities Reviews the medical records/case file, write a reconsideration/dispute resolution decision that is clear, concise, and impartial, supports the determination made, and documents the review. Makes fair, impartial, and independent decisions based on current medical evidence, statutes, regulations, rulings, policies, and procedures. Responds to and ensure that all appeal/dispute issues raised by the beneficiary/patient, representative, and provider/supplier have been addressed. Conducts research using online federal regulations, contract policy, standards of medical practice, contract manuals, coverage issues manuals, medical literature, and other related resources to make an accurate, 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 involving multiple beneficiaries/services in a single case. Plans responses to statistical analysis challenges with assistance from statisticians. Attends meetings and participate in workgroups at management's direction. Serves as a subject matter expert. Mentors and/or trains staff. Conducts quality reviews and audits, as needed. Participates in special projects and perform other duties as assigned. Requirements Required Experience and Skills Three (3) years of experience in medical dispute resolution, Medicare appeals, medical review, clinical work, or related healthcare roles. Healthcare Professional with experience in Nursing, Physical Therapy, Respiratory Therapy, or Occupational Therapy experience. Demonstrated experience writing or making medical necessity decisions. Proficiency in research techniques, medical terminology, and analyzing and interpreting policies, along with knowledge of state and federal laws and regulations. Must have experience and working knowledge of the Medicare program, including coverage and payment rules. Experience with Medicare regulations, claims processing, and the medical review process, as well as applicable laws, rules, and regulations. Prioritize and organize work tasks to handle multitasking and meet deadlines. Ability to prepare correspondence and documents using correct spelling, grammar, and punctuation; proofreading and reviewing documents for clarity and consistency. Practice logic and reasoning to identify problems, verify facts, and reach valid conclusions. Experience in making decisions that support business objectives and goals. Ability to identify and resolve problems or refer issues appropriately. Communicate effectively verbally and in writing. Adapt to the needs of internal and external customers. Show integrity and ethical behavior, respect confidentiality, business ethics, and organizational standards. Ensure compliance with company policies, procedures, and guidelines, including cybersecurity, regulatory, contractual, and accreditation entities. Experience directly relevant to Medicare managed care appeals or utilization management activities, preferred. Must have resided in the United States for a minimum of three (3) years out of the last five (5) years. This is a contractual requirement. Must possess a valid driver's license with a clear and satisfactory driving record. Ability to obtain and maintain public trust clearance and customer approval. Must be legally authorized to work in the United States without the need for employer sponsorship, now or at any time in the future. 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 an 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 Requires working in an office/cubicle environment; sitting, standing, walking, bending, twisting, and/or reaching. Prolonged periods of sitting at a desk and working on a computer. May need to lift 25 pounds occasionally. May require the ability to operate a motor vehicle and travel by motor vehicle and commercial airline. May require overnight travel. Travel may be less than 5% annually. Who We Are Tanaq Support Services (TSS) is a public health contractor and 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 develop effective 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, protected veteran status, or any other status protected by applicable federal, state, or local law. Tanaq complies with the Drug-Free Workplace Act of 1988 and participates in E-Verify. If you are an individual with a disability and need assistance completing any part of the application process, please email [email protected] 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 protect the integrity of the interview process, candidates may not use artificial intelligence (AI) tools to generate or assist with responses during phone, in-person, or virtual interviews. Candidates who require a reasonable accommodation that may involve AI must contact us before their interview at [email protected]. To view this and all our job postings, visit us at: https://recruiting.paylocity.com/recruiting/jobs/All/a4712c9f-f074-40e8-9a14-bee06660bd81/Tanaq-Support-Services-LLC