Clinical Appeals Reviewer (Licensed Healthcare Professional)
St. George Tanaq Corporation
Clinical Appeals Reviewer (Licensed Healthcare Professional)
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 Reviewer to support a contract with our federal client. The Clinical Appeals Professional performs complex (senior-level) work. Provides dissatisfied parties with the opportunity to present documentation to demonstrate why an appeal should be allowed. Provides an independent second level determination based on the documentation, facts, laws, regulations, and guidelines. Works under general supervision, with moderate latitude for the use of initiative and independent judgment. Qualified candidates must be licensed health care professionals capable of rendering independent clinical judgment, including but not limited to Registered Nurses (RN), Physical Therapists (PT), Occupational Therapists (OT), and Respiratory Therapists (RT).
This is a remote position that can be based anywhere in the United States. Must be able to work on a rotating schedule on weekends and holidays.
Responsibilities
Reviews medical records/case files, writes reconsideration decision letters that are clear, concise, and impartial, and support the determination made, and documents the review.
Makes sound, independent decisions based on medical evidence in accordance with statutes, regulations, rulings, and policy.
Responds to and ensures that all appeal 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.
Participates in case-specific verbal discussions.
Conducts reviews of appeals/disputes with multiple beneficiaries/services in one case.
Plans responses to statistical analysis challenges with assistance from statisticians.
Attends meetings and participates in workgroups at management's direction.
Conducts quality reviews, as needed.
Serves as a subject matter expert.
Mentors and/or trains staff.
May conduct quality reviews and audits.
Participates in special projects and performs other duties as assigned.
Requirements
Required Skills and Experience
Three (3) years of experience in medical dispute resolution, Medicare appeals, medical review, clinical work, or related healthcare roles.
Healthcare Professional with experience in Nursing, Physical Therapy, Respiratory Therapy, or Occupational Therapy experience.
Demonstrated experience writing or making medical necessity decisions.
Proficiency in research techniques, medical terminology, and analyzing and interpreting policies, along with knowledge of state and federal laws and regulations.
Must have experience and working knowledge of the Medicare program, including coverage and payment rules.
Experience with Medicare regulations, claims processing, and the medical review process, as well as applicable laws, rules, and regulations.
Prioritize and organize work tasks to handle multitasking and meet deadlines.
Ability to prepare correspondence and documents using correct spelling, grammar, and punctuation; proofreading and reviewing documents for clarity and consistency.
Practice logic and reasoning to identify problems, verify facts, and reach valid conclusions.
Experience in making decisions that support business objectives and goals.
Ability to identify and resolve problems or refer issues appropriately.
Communicate effectively verbally and in writing.
Adapt to the needs of internal and external customers.
Show integrity and ethical behavior, respect confidentiality, business ethics, and organizational standards.
Ensure compliance with company policies, procedures, and guidelines, including cybersecurity, regulatory, contractual, and accreditation entities.
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. This is a contractual requirement.
Must possess a valid driver's license with a clear and satisfactory driving record.
Ability to obtain and maintain public trust clearance and customer approval.
Must be legally authorized to work in the United States without the need for employer sponsorship, now or at any time in the future.
Education and Training
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 an Associate's degree on a year per year basis. (Experience requirements may be satisfied by full-time experience or the prorated part-time equivalent.)
Physical Requirements and Work Environment
Requires working in an office/cubicle environment; sitting, standing, walking, bending, twisting, and/or reaching.
Prolonged periods of sitting at a desk and working on a computer. May need to lift 25 pounds occasionally.
May require the ability to operate a motor vehicle and travel by motor vehicle and commercial airline. May require overnight travel. Travel may be less than 5% annually.
Who We Are
Tanaq Support Services (TMS) is a public health contractor, 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 understand and provide feedback as we develop solutions.
Our Commitment to Non-Discrimination
Tanaq is an Equal Employment Opportunity Employer. All qualified applicants will receive consideration for employment without regard to disability, status as a protected veteran or any other status protected by applicable federal, state, or local law. Tanaq complies with the Drug-free Workplace Act of 1988 and E-Verify.
If you are an individual with a disability and need assistance completing any part of the application process, please email View email address on click.appcast.io 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 ensure the integrity of the interview process, the use of artificial intelligence (AI) tools to generate or assist with responses during phone, in person and virtual interviews is not allowed. However, candidates who require a reasonable accommodation that may involve AI are required to contact us prior to their interview at View email address on click.appcast.io.
To apply for this positions, visit:
$88.7 - $98.55 per hour
...technology, services, and clinical expertise. Our... ...Medical Reviewer (M.D. or D.O.) (Remote... ...medical service appeal reviews for... ...current non-restricted license to practice... ...technologists, and industry professionals who come together... ...for the healthcare industry. State and...SuggestedWork experience placementLocal areaRemote workDay shift$83.1k - $120.36k
The Clinical Peer Reviewer (Phyiscal Therapy) Utilization Management (UM) plays a critical role in... ...role partners closely with UM nurses, Appeals & Grievances, Network Management, Medical... ...(MSPT) Active, unrestricted NYS PT license Minimum 5 years post-residency clinical...SuggestedWork experience placement$25.07 per hour
Overview Maximus is hiring a Clinical Reviewer to support the Illinois SALT program. The Clinical... ...the State of Illinois Department of Healthcare and Family Services (HFS) to manage... ...and resources tailored to your needs. Professional Development Opportunities - Participate...SuggestedRemote jobContract workTemporary workWork experience placementWork at officeHome officeMonday to Friday- ...home to one of the leading clinical trial networks in the country... ...relationships with healthcare professionals, patients, and families, while... ...Essential Functions: Reviews, compounds, prepares and/or... ...and unrestricted pharmacy license in Tennessee. Oncology experience...Suggested
- A healthcare organization in Tennessee is seeking a Physician Reviewer to ensure high-quality, cost-effective care for members.... ...This role involves reviewing clinical service requests, providing expert... ...offers opportunities for professional growth and a collaborative...Suggested
- ...Community presence: 20+ clinics across Nashville Flexible... ...resources Opportunities for professional development POSITION SUMMARY... ...records for medical staff review Posts test reports and other... ...patients we serve and the healthcare system overall. We hold that...Local areaWork from homeFlexible hours
$32 - $42 per hour
...collaboration platform trusted for healthcare. Guided by our mission to... ...benchmarks Foster professional communication with colleagues... ...hospital staff, while addressing clinical and reimbursement issues... ...significant level of coding quality review feedback Experience in...Hourly payFull timeRemote workRelocation packageFlexible hours- ...opportunities Health Advocates Network was founded based on a shared aspiration to improve the way healthcare staffing is done. We are a company founded by healthcare professionals and built for healthcare professionals. As your true advocates, we will always help you thrive...Daily paidLocal area
$73.4k - $120.36k
A healthcare organization seeks a Clinical Peer Reviewer (Physical Therapy) to ensure appropriate utilization of services. The ideal candidate will possess a Master's in Physical Therapy and 5 years of clinical experience. Responsibilities include reviewing authorization...- ...Medicine Cohort 20 Job Summary The Clinical Staff Leader is a direct... ...of an accredited program TN license or active compact license... ...Interact with and contribute to the professional development of their cohort... ...): Conducts performance reviews, delegates tasks, coaches subordinates...Temporary workWork experience placementFlexible hoursShift workNight shift
- ...to Inpatient Coder Transition Program LICENSES AND CERTIFICATIONS Required Must have one... ...appropriately to requests to code or review coded accounts for accuracy. Initiates... ...ATTIRE Uniform: No Scrubs: No Business professional: Yes Other (department approved): No ON...ApprenticeshipWork at office
- ...emergency room, therapy, and/or clinic encounters based upon... ...Inpatient Coder Transition Program LICENSES AND CERTIFICATIONS Required... ...promptly to requests to code or review coded accounts for accuracy.... ...: No Scrubs: No Business professional: Yes Other (department approved...Work at office
- ...appointments, and utilizing the Electronic Health Record system in a professional and efficient manner. Applicants with Athena EMR... ...know what drives us - our mission to improve the lives of our healthcare partners and their patients. Our actions speak louder than those...Full timeTemporary workPrivate practiceWork at office
$38k - $45.8k
...functioning as the welcoming face of our healthcare facility. Working onsite, you will... ...manage front desk operations, support clinical staff, and help maintain a smooth and compassionate... ...the phone, creating a welcoming and professional atmosphere. Schedule and confirm...Full timeTemporary workApprenticeshipFlexible hours$18 - $22 per hour
...- we're revolutionizing how people access healthcare. As the nation's leading urgent care provider with over 200 clinics across 26 states, we're looking for a detail... ...of AFC: Greet patients with the warmth and professionalism that makes AFC stand out in healthcare...Hourly payPart timeReliefWork at officeFlexible hoursShift workWeekend workAfternoon shift- ...with transitional care and start of care conversation required. Licensed Practical Nurse (LPN) would be nice for the role. The... ...to read, analyze, and interpret general business periodicals, professional journals, technical procedures, or governmental regulations. Ability...Flexible hours
- ...individual is responsible for effectively and professionally managing patient flow from arrival to... ...clerical duties; interacts with other clinic personnel, patients and visitors, and... ...and procedures. Certificates, Licenses, Registrations ~ Valid and unrestricted...Full timeWork at officeFlexible hoursShift work
- ...system in Nashville, TN, is seeking a Full-Time Administrative professional to craft various forms of written communication, assist with... ...growth and care, contributing to the overall mission of providing quality healthcare to communities. #J-18808-Ljbffr Ascension HealthFull timeDay shift
- ...Receptionist must effectively and professionally manage patient flow from... ...duties; interacts with other clinic personnel, patients and visitors... ...and orderly work area. Review Phone Tree reports and conduct... ...laws. Certificates, Licenses, Registrations ~ None required...Full timeWork at officeShift workNight shiftDay shift
- ...personalization, behavioral healthcare can leave people feeling... ...passionate, forward-thinking professionals eager to take on the... ...leadershipResponsible for reviewing and appealing denied claims for bundling... ...Please do not call our public clinical admissions line in regard...Full timeWork at officeLocal area
- ...undergraduate and graduate healthcare programs for our students.... ...Physician Assistant Program Clinical Administrator. The Clinical... ...Assistant Studies program. Professional duties will include but not... ...faxing and electronic records review, clinical documentation 2....Full timeWork at office
- ...communication processes to both patients and clinic employees. The Patient Care Specialist... ...other team members to achieve a strong professional appearance for our employees, patients... ...Diploma or its equivalent with a current CPR license* and at least 1 year of customer...Seasonal work
- ...opening for an experienced Certified Clinical Medical Assistant (CCMA) or Registered... ...protocols and expectations. Performs duties professionally while showing courteous and cooperative... ...laws. For further information, please review the Know Your Rights notice from the...Full timeRelocationMonday to Friday
- Maximus is seeking a Clinical Reviewer in Nashville, Tennessee to evaluate assessments and determine needs for additional supports. This role involves quality control reviews ensuring accuracy and compliance with state and federal policies. The position offers competitive...Remote job
- Software Technology, Inc. is seeking a Registered Nurse licensed in Tennessee to provide nursing care according to physician orders.... ...necessitates effective communication and basic life support skills in a healthcare environment. #J-18808-Ljbffr Software Technology, Inc.
- ...for a full-time, entry-level Clinical Assistant position. This... ...specifically designed for future healthcare professionalsparticularly... ...Attributes: Exceptional professionalism, strong work ethic, high reliability... ...prescriptions for provider review and authorization. Care...Full timeFlexible hours
- ...Community presence: 20+ clinics across Nashville Flexible... ...resources Opportunities for professional development POSITION SUMMARY... ...preferred Background in healthcare is preferred Background... ...from. Compensation Reviews, Career Growth Opportunities...Local areaWork from homeFlexible hours
$16 - $21.1 per hour
...of a global workforce of revenue cycle professionals with the industry’s most advanced... ...any previous experience or knowledge in healthcare. Since this is a hospital/lab environment... ...the registration process for emergent clinical care. Helping people who may be very...Hourly payPart timeCasual workReliefLocal areaShift work$16 - $21.1 per hour
...of a global workforce of revenue cycle professionals with the industry's most advanced technology... ...previous experience or knowledge in healthcare. Since this is a hospital/lab... ...the registration process for emergent clinical care. Helping people who may be very...Hourly payPart timeCasual workReliefLocal areaShift work$107.82k - $145.88k
...expertise every day to reimagining healthcare, together. Recognized as one... ...), reimbursement, ongoing professional development and online... ...impact in this role Lead clinical incident investigations in partnership... ...facility leadership. Review and validate candidate...Full timeLocal areaRemote workDay shift
Do you want to receive more vacancies?
Subscribe and receive similar vacancies to Clinical Appeals Reviewer (Licensed Healthcare Professional). Be the first to apply!
- medical records reviewer remote Nashville, TN
- medical reviewer Nashville, TN
- medical record assistant Nashville, TN
- medical records reviewer Nashville, TN
- clinical reviewer Nashville, TN
- health records assistant Nashville, TN
- remote clinical documentation specialist Nashville, TN
- medical records administrator Nashville, TN
- medical records clerk Nashville, TN
- clinical documentation specialist Nashville, TN


