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Clinical Appeals & Grievances Nurse Reviewer

Fully Remote•United States

Job Type

Full-time

Description

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 Clinical Appeals & Grievances Nurse Reviewer (Dispute Resolution Reviewer III) to support our federal client. The ideal candidate 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 role works under general supervision with moderate latitude for initiative and independent judgment.

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. 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.

• Mentors and/or trains staff.

• Conduct quality reviews and audits, as needed.

• Participate in special projects and perform other duties as assigned.

Requirements

Required Experience and Skills

• 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 Nurse license with no restrictions and in good standing.

• Demonstrated experience writing or making appeal or payment determinations

• Experience using Microsoft 365, including Excel and Word.

• Must be able to pass Federal and state criminal background checks, as required by client.

• Must be able to pass education, certification and license verification, as well as other professional background checks, as required by client.

• Must be able to pass drug screen, as required by client.

• Must be legally authorized to work in the United States without the need for employer sponsorship, now or at any time in the future.

Preferred Qualifications

• Experience with medical necessity determinations, payments, and billing/claims experience.

• Experience working with or supporting a federal public health agency environment.

• Patient-Provider Dispute Resolution or Independent Dispute Resolution experience.

• Coding certification.

Education and Training

• Must be an actively licensed healthcare professional with Nursing, Physical Therapy, Respiratory Therapy, Occupational Therapy, or closely related clinical experience.

Physical Requirements

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

Who We Are

Tanaq Support Services (TSS) is a public health contractor and certified 8(a) business owned by St. George Tanaq Corporation, an Alaska Native Corporation (ANC). We listen to our stakeholders and leverage our science, technology, communication, and program expertise to develop effective solutions.

Our commitment to non-discrimination

Tanaq Support Services is an Equal Employment Opportunity Employer. All qualified applicants will receive consideration for employment without regard to disability, protected veteran status, or any other status protected by applicable federal, state, or local law. Tanaq complies with the Drug-Free Workplace Act of 1988 and participates in E-Verify.

If you are an individual with a disability and need assistance completing any part of the application process, please email accommodation@tanaq.com to request a reasonable accommodation. This email is for accommodation requests only and cannot be used to inquire about the status of applications.

Notice on candidate AI usage

Tanaq is committed to ensuring a fair and competitive interview process for all candidates based on their experience, skills, and education. To protect the integrity of the interview process, candidates may not use artificial intelligence (AI) tools to generate or assist with responses during phone, in-person, or virtual interviews. Candidates who require a reasonable accommodation that may involve AI must contact us before their interview at accommodation@tanaq.com.

To view this and all our job postings, visit us at:

https://recruiting.paylocity.com/recruiting/jobs/All/a4712c9f-f074-40e8-9a14-bee06660bd81/Tanaq-Support-Services-LLC