Job Description

Please make sure your application is complete, including your education, employment history, and any other applicable sections. Initial screening is based on the minimum requirements as defined in the job posting, such as education, experience, licenses, and certifications. Your experience should also address the knowledge, skills and abilities needed for the role. Incomplete applications will not be considered. *This position is located Remote, Anywhere US* Position Purpose: Provides dissatisfied patients/beneficiaries and/or providers the opportunity to present documentation to demonstrate why an appeal/dispute should be allowed. Provides an independent second level determination/dispute resolution based on the documentation, facts, laws, regulations, and guidelines. Essential Responsibilities: Reviews medical records/case file, writes a reconsideration/dispute resolution decision that is clear, concise, and impartial and supports the determination made, and documents review. Makes sound, independent decisions based on medical evidence in accordance with statutes, regulation, rulings, and policy. Responds to and ensures that all appeal/dispute 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. Minimum Qualifications Education Associate's degree or 60 or more credit hours towards a Bachelor's degree from an accredited college or university in healthcare or related discipline Additional experience in Medicare appeals, medical review, clinical, or other related experience in a healthcare setting may be substituted for Associate's degree on a year per year basis. (Experience requirements may be satisfied by full-time experience or the prorated part-time equivalent.) Experience Three (3) years of medical dispute resolution or Medicare appeals, medical review, clinical, or related experience in a healthcare setting Healthcare Professional with Nursing, Physical Therapy, Respiratory Therapy or Occupational Therapy experience Juris Doctorate or Master's Degree in Healthcare or related discipline may be substituted for Healthcare Professional with Nursing, Physical Therapy, Respiratory Therapy or Occupational Therapy experience Demonstrated experience writing or making appeal or payment determinations Patient- Provider Dispute Resolution, preferred Independent Dispute Resolution, preferred Coding certificate, preferred Benefits C2C offers an excellent benefits package, including: Medical, dental, vision, life, accidental death and dismemberment, and short and long-term disability insurance Section 125 plan 401K Competitive salary License/credentials reimbursement Tuition Reimbursement EOE Vet/Disability Equal Opportunity Employer/Protected Veterans/Individuals with Disabilities This employer is required to notify all applicants of their rights pursuant to federal employment laws. For further information, please review the Know Your Rights notice from the Department of Labor. TMF Health Quality Institute

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