Dispute Resolution Reviewer III (Healthcare Professional)

Role Overview

This role entails analyzing medical documentation from patients, beneficiaries, or providers to resolve disputes and appeals independently. The reviewer ensures decisions are impartial, evidence-based, and compliant with applicable laws, regulations, and policies, facilitating fair outcomes.

Key Responsibilities

• Carefully examine case files and medical records to produce clear and precise dispute resolution reports supporting decisions.
• Address all appeal-related questions raised by involved parties, ensuring thorough evaluations.
• Perform research leveraging federal regulations, medical literature, and internal policies to support decision-making.
• Maintain current knowledge of healthcare regulations, policies, and best practices.

Qualifications and Expertise

• Completion of an associate's degree or accumulation of 60 or more credit hours toward a bachelor's degree in healthcare or a related discipline; relevant professional experience may substitute formal education requirements.
• Minimum of three years' relevant experience in medical dispute resolution, Medicare appeals, or comparable healthcare roles.
• Professional healthcare background such as nursing, physical therapy, respiratory therapy, or occupational therapy; alternatively, legal or advanced academic qualifications may substitute for experience.
• Proven track record in writing appeal decisions or payment determinations; prior independent dispute resolution experience is favorable.
• Proficient in making sound, evidence-based decisions guided by rules, regulations, and documented policies.

Additional Information

• This is a fully remote position based within the United States.
• Employment benefits include health insurance, 401(k) retirement plan, tuition reimbursement, and support for credentialing processes.