TMF Health Quality Institute
Dispute Resolution Reviewer II
TMF Health Quality Institute, Austin, Texas, us, 78716
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:
Performs complex (senior-level) work.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.Works under general supervision, with moderate latitude for the use of initiative and independent judgment.
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.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 settingHealthcare Professional with demonstrated experience writing or making medical necessity decisionsNursing, Physical Therapy, Respiratory Therapy or Occupational Therapy experienceMedical billing, medical appeals or clinical experiencePatient- Provider Dispute Resolution, preferredIndependent Dispute Resolution, preferredCoding certificate, preferredBenefits
C2C offers an excellent benefits package, including:
Medical, dental, vision, life, accidental death and dismemberment, and short and long-term disability insuranceSection 125 plan401KCompetitive salaryLicense/credentials reimbursementTuition Reimbursement
EOE Minorities/Females/Vet/Disability
Equal Opportunity Employer/Protected Veterans/Individuals with Disabilities
The contractor will not discharge or in any other manner discriminate against employees or applicants because they have inquired about, discussed, or disclosed their own pay or the pay of another employee or applicant. However, employees who have access to the compensation information of other employees or applicants as a part of their essential job functions cannot disclose the pay of other employees or applicants to individuals who do not otherwise have access to compensation information, unless the disclosure is (a) in response to a formal complaint or charge, (b) in furtherance of an investigation, proceeding, hearing, or action, including an investigation conducted by the employer, or (c) consistent with the contractor's legal duty to furnish information. 41 CFR 60-1.35(c)
*This position is located Remote Anywhere US*
Position Purpose:
Performs complex (senior-level) work.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.Works under general supervision, with moderate latitude for the use of initiative and independent judgment.
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.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 settingHealthcare Professional with demonstrated experience writing or making medical necessity decisionsNursing, Physical Therapy, Respiratory Therapy or Occupational Therapy experienceMedical billing, medical appeals or clinical experiencePatient- Provider Dispute Resolution, preferredIndependent Dispute Resolution, preferredCoding certificate, preferredBenefits
C2C offers an excellent benefits package, including:
Medical, dental, vision, life, accidental death and dismemberment, and short and long-term disability insuranceSection 125 plan401KCompetitive salaryLicense/credentials reimbursementTuition Reimbursement
EOE Minorities/Females/Vet/Disability
Equal Opportunity Employer/Protected Veterans/Individuals with Disabilities
The contractor will not discharge or in any other manner discriminate against employees or applicants because they have inquired about, discussed, or disclosed their own pay or the pay of another employee or applicant. However, employees who have access to the compensation information of other employees or applicants as a part of their essential job functions cannot disclose the pay of other employees or applicants to individuals who do not otherwise have access to compensation information, unless the disclosure is (a) in response to a formal complaint or charge, (b) in furtherance of an investigation, proceeding, hearing, or action, including an investigation conducted by the employer, or (c) consistent with the contractor's legal duty to furnish information. 41 CFR 60-1.35(c)