Dispute Resolution Reviewer III (Healthcare Professional)

Tmf/C2C • Austin, TX

1d • Remote

About The Position

Provides dissatisfied patients/beneficiaries and/or providers the opportunity to present documentation to demonstrate why an appeal/dispute should be allowed. Provides an independent second level determination/dispute resolution based on the documentation, facts, laws, regulations, and guidelines.

Requirements

• 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
• Three (3) years of medical dispute resolution or Medicare appeals, medical review, clinical, or related experience in a healthcare setting
• Healthcare Professional with Nursing, Physical Therapy, Respiratory Therapy or Occupational Therapy experience
• Demonstrated experience writing or making appeal or payment determinations
• Resided in the United States for a minimum of three (3) years out of the last five (5) years (Per Contract Requirement)

Nice To Haves

• Additional experience in Medicare appeals, medical review, clinical, or other related experience in a healthcare setting may be substituted for Associate’s degree on a year per year basis.
• Independent Dispute Resolution, preferred
• Juris Doctorate or Master’s Degree in Healthcare or related discipline may be substituted for Healthcare Professional with Nursing, Physical Therapy, Respiratory Therapy or Occupational Therapy experience

Responsibilities

• Reviews medical records/case file, writes a reconsideration/dispute resolution decision that is clear, concise, and impartial and supports the determination made, and documents review.
• Makes sound, independent decisions based on medical evidence in accordance with statutes, regulation, rulings, and policy.
• Responds to and ensures that all appeal/dispute issues raised by the beneficiary/patient, representative, and provider/supplier have been addressed.
• Provides a fair and impartial decision based on current evidence, regulations, policies, and procedures.
• Conducts research using online federal regulations, contract policy, standards of medical practice, contract manuals, coverage issues manuals, medical literature, and other related resources to complete an accurate and well-supported decision.
• Stays abreast of changes in regulations, medical and healthcare practices, policies and procedures.

Benefits

• Medical, dental, vision, life, accidental death and dismemberment, and short and long-term disability insurance
• Section 125 plan
• 401K
• Competitive salary
• License/credentials reimbursement
• Tuition Reimbursement

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: Associate degree