Appeals Professional III – Licensed Clinician

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Tanaq Government Services, LLC

WebsiteLinkedInAll Job Openings

2 - 10 employees

Founded 2016

🏛️ Government

📦 Logistics

🏥 Healthcare

Government • Logistics • Healthcare

Tanaq Government Services, LLC is a wholly owned subsidiary of St. George Tanaq Corporation (an Alaska Native Corporation) and an SBA 8(a) certified small business based in Anchorage, Alaska. Tanaq has two business units: Base Operations Support (BOS), which provides facilities and base-support services including electrical, plumbing, HVAC, mechanical work, preventative/predictive maintenance, facilities management, general maintenance, aviation maintenance, inventory and asset management, purchasing, and shipping/receiving/storage; and Tanaq Health, which offers administrative and professional support, health science services, data management, and staff augmentation. TGS focuses on delivering compliant, efficient, and economical support services to government and institutional clients.

📋 Description

• Review medical records and case files. • Write clear, concise, and impartial reconsideration decision letters and document reviews. • Make independent decisions based on medical evidence, statutes, regulations, rulings, and policy. • Address all appeal issues raised by beneficiaries/patients, representatives, and providers/suppliers. • Conduct research using federal regulations, contract policies, medical-practice standards, manuals, medical literature, and related resources. • Stay current with changes in regulations, healthcare practices, policies, and procedures. • Participate in case-specific verbal discussions. • Review appeals/disputes involving multiple beneficiaries or services in one case. • Plan responses to statistical-analysis challenges with assistance from statisticians. • Attend meetings and participate in management-directed workgroups. • Conduct quality reviews and audits as needed. • Serve as a subject matter expert. • Mentor and/or train staff. • Participate in special projects and perform other assigned duties.

🎯 Requirements

• Three (3) years of experience in medical dispute resolution, Medicare appeals, medical review, clinical work, or related healthcare roles. • Experience in Nursing, Physical Therapy, Respiratory Therapy, or Occupational Therapy. • Demonstrated experience writing or making medical necessity decisions. • Proficiency in research techniques and medical terminology. • Ability to analyze and interpret policies, and knowledge of state and federal laws and regulations. • Working knowledge of the Medicare program, including coverage and payment rules. • Experience with Medicare regulations, claims processing, the medical review process, and applicable laws, rules, and regulations. • Ability to prioritize and organize tasks, multitask, and meet deadlines. • Ability to prepare and proofread correspondence and documents using correct spelling, grammar, punctuation, clarity, and consistency. • Logic and reasoning skills to identify problems, verify facts, and reach valid conclusions. • Experience making decisions that support business objectives and goals. • Ability to identify and resolve problems or refer issues appropriately. • Effective verbal and written communication. • Ability to adapt to internal and external customer needs. • Integrity, ethical behavior, confidentiality, business ethics, and organizational standards. • Ability to comply with cybersecurity, regulatory, contractual, and accreditation requirements. • Experience directly relevant to Medicare managed care appeals or utilization management activities preferred. • Must have resided in the United States for at least three (3) years out of the last five (5) years. • Must possess a valid driver's license with a clear and satisfactory driving record. • Ability to obtain and maintain public trust clearance and customer approval. • Must be legally authorized to work in the United States without employer sponsorship, now or in the future. • Associate's degree or 60 or more credit hours toward a Bachelor's degree from an accredited college or university in healthcare or a related discipline, with additional relevant experience substitutable year for year. • Ability to work Eastern, Central, or Mountain Time Zone business hours and on a rotating schedule on weekends and holidays. • Ability to work in an office/cubicle environment, sit for prolonged periods, work on a computer, and occasionally lift 25 pounds. • Ability to operate a motor vehicle and travel by motor vehicle or commercial airline, including possible overnight travel.

🏖️ Benefits

• Remote position • Travel may be less than 5% annually • Equal Employment Opportunity Employer • Reasonable accommodation for applicants with disabilities • Drug-free workplace • E-Verify