Medicare Appeals Professional
Overview
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 Medicare Appeals Professional to support a contract with our federal client. The appeals professional performs complex (senior-level) work. Provides dissatisfied parties with the opportunity to present documentation to demonstrate why an appeal should be allowed. Provides an independent second level determination based on the documentation, facts, laws, regulations, and guidelines. Works under general supervision, with moderate latitude for the use of initiative and independent judgment This is a remote position that can be based anywhere in the United States. Must be able to work on a rotating schedule on weekends and holidays.
Responsibilities
- Reviews medical records/case files, writes reconsideration decision letters that are clear, concise, and impartial, and support the determination made, and documents the review.
- Makes sound, independent decisions based on medical evidence in accordance with statutes, regulations, rulings, and policy.
- Responds to and ensures that all appeal 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.
- Participates in case-specific verbal discussions.
- Conducts reviews of appeals/disputes with multiple beneficiaries/services in one case.
- Plans responses to statistical analysis challenges with assistance from statisticians.
- Attends meetings and participates in workgroups at management's direction.
- Conducts quality reviews, as needed.
- Serves as a subject matter expert.
- Mentors and/or trains staff.
- May conduct quality reviews and audits.
- Participates in special projects and performs other duties as assigned.
Requirements
Required Skills and Experience
- Three (3) years of experience in medical dispute resolution, Medicare appeals, medical review, clinical work, or related healthcare roles.
- Healthcare Professional with experience in Nursing, Physical Therapy, Respiratory Therapy, or Occupational Therapy experience.
- Demonstrated experience writing or making medical necessity decisions.
- Proficiency in research techniques, medical terminology, and analyzing and interpreting policies, along with knowledge of state and federal laws and regulations.
- Must have experience and working knowledge of the Medicare program, including coverage and payment rules.
- Experience with Medicare regulations, claims processing, and the medical review process, as well as applicable laws, rules, and regulations.
- Prioritize and organize work tasks to handle multitasking and meet deadlines.
- Ability to prepare correspondence and documents using correct spelling, grammar, and punctuation; proofreading and reviewing documents for clarity and consistency.
- Practice logic and reasoning to identify problems, verify facts, and reach valid conclusions.
- Experience in making decisions that support business objectives and goals.
- Ability to identify and resolve problems or refer issues appropriately.
- Communicate effectively verbally and in writing.
- Adapt to the needs of internal and external customers.
- Show integrity and ethical behavior, respect confidentiality, business ethics, and organizational standards.
- Ensure compliance with company policies, procedures, and guidelines, including cybersecurity, regulatory, contractual, and accreditation entities.
- Experience directly relevant to Medicare managed care appeals or utilization management activities, preferred.
- Must have resided in the United States for a minimum of three (3) years out of the last five (5) years. This is a contractual requirement.
- Must possess a valid driver's license with a clear and satisfactory driving record.
- Ability to obtain and mainta
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