Clinical Appeals & Grievances Nurse Reviewer

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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 for complex Medicare appeals and disputes • Write clear, concise, impartial reconsideration and dispute-resolution decisions supported by medical evidence and policy • Make independent determinations based on medical evidence, statutes, regulations, rulings, policies, procedures, and applicable guidelines • Address all appeal and dispute issues raised by beneficiaries/patients, representatives, and providers/suppliers • Research federal regulations, contract policies, medical-practice standards, manuals, coverage-issues manuals, medical literature, and related resources • Stay current on regulatory, medical, healthcare-practice, policy, and procedural changes • Participate in case-specific verbal discussions • Review appeals and disputes involving multiple beneficiaries or services in a single case • Plan responses to statistical-analysis challenges with assistance from statisticians • Attend meetings and participate in management-directed workgroups • 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 assigned duties

🎯 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, unrestricted Nurse license in good standing; licenses with restrictions or encumbrances are not eligible • Demonstrated experience writing or making appeal or payment determinations • Experience using Microsoft 365, including Excel and Word • Must pass Federal and state criminal background checks, as required by the client • Must pass education, certification, and license verification and other professional background checks, as required by the client • Must pass a drug screen, as required by the client • Must be legally authorized to work in the United States without employer sponsorship, now or in the future • Preferred: experience with medical necessity determinations, payments, and billing/claims • Preferred: experience supporting a federal public health agency environment • Preferred: Patient-Provider Dispute Resolution or Independent Dispute Resolution experience • Preferred: coding certification • Must be an actively licensed healthcare professional with nursing, physical therapy, respiratory therapy, occupational therapy, or closely related clinical experience • Must work Eastern, Central, or Mountain Time Zone business hours and be available for rotating weekend and holiday schedules • Prolonged periods of sitting at a desk and working on a computer • May occasionally need to lift 25 pounds

🏖️ Benefits

• Fully remote position • Opportunity to support a federal client • Participation in special projects, workgroups, and professional activities • Mentoring and/or training opportunities