Medicare Clinical Appeals Reviewer III

Overview

Tanaq Support Services (TSS), a subsidiary of the St. George Tanaq Corporation (an Alaskan Native Corporation), provides professional, scientific, technical, and IT services to federal agencies across health, agriculture, technology, and other government sectors. TSS is dedicated to serving federal customers while supporting the Tanaq native community and shareholders.

Role Summary

We are looking for a Medicare Clinical Appeals Reviewer III, also known as Dispute Resolution Reviewer III, to assist our federal client. This licensed healthcare professional independently assesses complex Medicare appeals and disputes by reviewing clinical documentation, interpreting federal regulations, and issuing appeal decisions grounded in medical evidence and policies. The role includes making independent second-level determinations and dispute resolutions by analyzing documentation, laws, regulations, and applicable guidelines. It requires working under general supervision while exercising moderate independence and judgment. The position is fully remote, requiring candidates to be based in the United States and able to work during Eastern, Central, or Mountain Time business hours.

Responsibilities

• Thoroughly review medical records and case files to compile clear, concise, and unbiased reconsideration or dispute resolution decisions that support the determinations made and document the review process.
• Render fair, independent decisions founded on current medical evidence, statutes, regulations, rulings, policies, and procedures.
• Ensure all concerns raised by beneficiaries, representatives, and providers are addressed comprehensively.
• Utilize online federal regulations, contract policies, medical standards, manuals, medical literature, and related resources to support well-informed, accurate decisions.
• Stay updated with evolving regulations, healthcare practices, policies, and procedures.
• Participate in case-specific verbal discussions and reviews involving multiple beneficiaries or services within single cases.
• Collaborate with statisticians to devise strategies for responding to statistical analysis challenges.
• Attend meetings and contribute to workgroups as directed by management.
• Function as a subject matter expert, mentor, and trainer for staff members.
• Conduct quality reviews and audits as required.
• Engage in special projects and execute other assigned duties.

Requirements

• Possess 2 to 3 years of experience in medical dispute resolution, Medicare appeals, medical or clinical review, or related healthcare settings.
• Hold professional experience in Nursing, Physical Therapy, Respiratory Therapy, or Occupational Therapy; candidates with closely related clinical or medical experience and appropriate licensure may also qualify.
• Demonstrate experience in drafting or making appeal or payment determinations.
• Proficiency in Microsoft 365 applications, including Excel and Word.
• Ability to pass federal and state criminal background checks, education, certification, license verification, professional background checks, and drug screening as required by the client.
• Legal authorization to work in the United States without requiring employer sponsorship now or in the future.

Preferred Qualifications

• Experience with Medicare appeals, healthcare compliance reviews, or independent dispute resolution processes.
• Background in making determinations regarding appeals, payments, billing, or dispute resolution.
• Familiarity with federal public health agency environments.
• Experience in Patient-Provider Dispute Resolution or Independent Dispute Resolution.
• Coding certification is advantageous.

Education and Training

Candidates must hold an active license in Nursing, Physical Therapy, Respiratory Therapy, Occupational Therapy, or have closely related clinical experience.

Physical Requirements

• Work entails prolonged sitting at a desk and computer use; lifting up to 25 pounds may be occasionally necessary.

Equal Opportunity and Compliance

Tanaq Support Services is committed to equal employment opportunity, providing fair consideration regardless of disability, veteran status, or other protected factors. The company complies with the Drug-Free Workplace Act and participates in E-Verify.

Accessibility

Applicants needing assistance during the application process due to disability may request reasonable accommodations via email provided for accommodation requests only.

Interview Policy

Tanaq promotes a fair interview experience based on candidates' qualifications. Use of artificial intelligence tools during interviews is prohibited unless accommodation arrangements have been made beforehand.