Medicare Clinical Appeals Reviewer, RN, PT, OT, RT

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🇺🇸 United States – Remote

⏰ Full Time

🟡 Mid-level

🟠 Senior

👻 Ghost score 13%

What it means: how likely this posting is sitting open without active hiring.How to read it: 60% or higher means we think this is a ghost. Lower scores are less of a worry.How we score it: age, reposts, open roles vs team size, how fast jobs close, and whether pay is listed.Fine print: an estimate from public data, not a judgment of the company. Real jobs can score high, so treat it as a hint, not a fact.

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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, impartial reconsideration/dispute resolution decisions that document and support determinations • Make fair, impartial, and independent decisions based on current medical evidence, statutes, regulations, rulings, policies, and procedures for Medicare Part C appeals • Ensure all appeal/dispute issues raised by beneficiaries/patients, representatives, and providers/suppliers are addressed • Research federal regulations, contract policy, medical practice standards, manuals, coverage issues, medical literature, and related resources • Stay current with changes in regulations, medical and healthcare practices, policies, and procedures • Participate in case-specific verbal discussions • Review appeals/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 workgroups as directed by management • 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

• Active, unrestricted license in good standing as an RN, PT, RT, OT, or other qualifying licensed healthcare professional • 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, medical terminology, and analyzing and interpreting policies • 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, and the medical review process • Ability to prioritize and organize work tasks, multitask, and meet deadlines • Ability to prepare, proofread, and review correspondence and documents for 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 and ethical behavior; respect for confidentiality, business ethics, and organizational standards • Compliance with company policies, procedures, 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 a minimum of three (3) years out of the last five (5) years • Valid driver's license with a clear and satisfactory driving record • Ability to obtain and maintain public trust clearance and customer approval • 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 • Additional relevant experience may substitute for an Associate's degree on a year-per-year basis • Ability to work Eastern, Central, or Mountain Time Zone business hours • Ability to work in an office/cubicle environment and sit, stand, walk, bend, twist, and/or reach • Ability to work prolonged periods at a desk and computer • May need to lift 25 pounds occasionally • May require operation of a motor vehicle and travel by motor vehicle or commercial airline • May require overnight travel

🏖️ Benefits

• Fully remote work arrangement • Equal Employment Opportunity protections • Reasonable accommodation support for individuals with disabilities