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

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.