Clinical Appeals & Grievances Nurse Reviewer

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 Clinical Appeals & Grievances Nurse Reviewer (Dispute Resolution Reviewer III) to support our federal client. The ideal candidate is a licensed clinician who independently evaluates complex Medicare appeals and dispute cases, reviews clinical documentation, interprets federal regulations, and issues appeal determinations supported by medical evidence and policy. They will also provide independent second-level determinations and dispute resolutions based on documentation, facts, laws, regulations, and applicable guidelines. This role works under general supervision with moderate latitude for initiative and independent judgment. 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 with availability to work on a rotating schedule on weekends and holidays.

Required: Active, unrestricted license in good standing as an RN. Licenses with restrictions or encumbrances are not eligible.

Responsibilities

• Review 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.
• Make fair, impartial, and independent decisions based on current medical evidence, statutes, regulations, rulings, policies, and procedures.
• Respond to and ensure that all appeal/dispute issues raised by the beneficiary/patient, representative, and provider/supplier have been addressed.
• Conduct 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.
• Stay abreast of changes in regulations, medical and healthcare practices, policies, and procedures.
• Participate in case-specific verbal discussions.
• Conduct reviews of appeals/disputes involving multiple beneficiaries/services in a single case.
• Plan responses to statistical analysis challenges with assistance from statisticians.
• Attend meetings and participate in workgroups at management's direction.
• Serve as a subject matter expert.
• Mentor and/or train staff.
• Conduct quality reviews and audits, as needed.
• Participate in special projects and perform other duties as assigned.

Requirements

• Must have 3 years of experience in medical dispute resolution, Medicare appeals, medical review, clinical review, or a related healthcare setting.
• Must have an active Nurse license with no restrictions and in good standing.
• Demonstrated experience writing or making appeal or payment determinations.
• Experience using Microsoft 365, including Excel and Word.
• Must be able to pass Federal and state criminal background checks, as required by client.
• Must be able to pass education, certification and license verification, as well as other professional background checks, as required by client.
• Must be able to pass drug screen, as required by client.
• Must be legally authorized to work in the United States without the need for employer sponsorship, now or at any time in the future.

Qualifications

• Experience with medical necessity determinations, payments, and billing/claims experience.
• Experience working with or supporting a federal public health agency environment.
• Patient-Provider Dispute Resolution or Independent Dispute Resolution experience.
• Coding certification.

Must be an actively licensed healthcare professional with Nursing, Physical Therapy, Respiratory Therapy, Occupational Therapy, or closely related clinical experience.

Physical Requirements

Prolonged periods of sitting at a desk and working on a computer. May need to lift 25 pounds occasionally.