Dispute Resolution Reviewer I

Responsibilities

• Review medical records and case files to make clear, impartial decisions supporting the determination
• Provide independent second-level determinations for appeals related to enrollment denials, revocations, or suspensions
• Ensure all issues raised by beneficiaries, providers, or suppliers are addressed
• Conduct research using federal regulations, policies, medical literature, and other resources to support accurate decisions
• Write concise, well-supported decisions based on evidence, laws, and guidelines

Qualifications & Skills

• Associate's degree or 60+ credit hours in healthcare or related fields; experience may substitute for education
• At least one year of experience in Medicare appeals, medical review, or healthcare regulatory interpretation
• Ability to make sound, independent decisions based on medical evidence and regulations
• Strong research skills and knowledge of healthcare policies and laws

This role involves making fair, evidence-based determinations in a remote setting, emphasizing impartiality, research, and thorough documentation.