Dispute Resolution Reviewer I

Job TitleProvides dissatisfied beneficiaries and/or providers the opportunity to present documentation or evidence to demonstrate why an appeal or rebuttal for an enrollment denial, revocation, or suspension should be allowed. Provides an independent second level determination based on the documentation, facts, laws, regulations, and guidelines.Essential Responsibilities:Reviews medical records/case file, writes a 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 issues raised by the beneficiary, representative, supplier, and provider 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 QualificationsEducation: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:One (1) year of Medicare appeals, medical review, clinical, healthcare regulatory interpretation/application, healthcare compliance or related experience in a healthcare settingIndependent Dispute Resolution Experience, preferredResided in the United States for a minimum of three (3) years out of the last five (5) years (Per Contract Requirement)Benefits:Medical, dental, vision, life, accidental death and dismemberment, and short and long-term disability insuranceSection 125 plan401KCompetitive salaryLicense/credentials reimbursementTuition ReimbursementEOE Vet/DisabilityEqual 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.