Medicare Clinical Appeals Reviewer III

Tanaq Health is a division of St. George Tanaq (SGT) Corporation, an Alaskan Native Corporation dedicated to serving federal customers while supporting the Tanaq native community and shareholders through dividends, scholarships, elder care, and other programs. Tanaq Health encompasses SGT subsidiaries focused on federal health initiatives, delivering innovative, compliant, and cost-effective services in health communication, science and research, informatics and information systems, mission and programmatic support, and laboratory science. Team members contribute to federal health efforts that have national impact, while being part of an organization grounded in community values and long-term stewardship.

About the Role

We are seeking a Medicare Clinical Appeals Reviewer III (Dispute Resolution Reviewer III) to support our federal client. This role 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 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, PT, RT, OT, or other qualifying licensed healthcare professional. 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

• 2-3 years of experience in medical dispute resolution, Medicare appeals, medical review, clinical review, or a related healthcare setting.
• Nursing, Physical Therapy, Respiratory Therapy, or Occupational Therapy experience. Licensed candidates with closely related clinical or medical experience may be considered.
• Demonstrated experience writing or making appeal or payment determinations.
• Experience using Microsoft 365, including Excel and Word.
• Ability to pass Federal and state criminal background checks, as required by client.
• Ability to pass education, certification, and license verification, as well as other professional background checks, as required by client.
• Ability to pass drug screen, as required by client.
• Legally authorized to work in the United States without the need for employer sponsorship, now or at any time in the future.

Qualifications

• Actively licensed healthcare professional with Nursing, Physical Therapy, Respiratory Therapy, Occupational Therapy, or closely related clinical experience.

Preferred Qualifications

• Medicare appeals, medical review, healthcare compliance review, or independent dispute resolution experience.
• Experience making determinations on appeals, payments, billing, or dispute resolution.
• Experience working with or supporting a federal public health agency environment.
• Patient-Provider Dispute Resolution or Independent Dispute Resolution experience.
• Coding certification.

Physical Requirements

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