Appeals Professional II

Appeals Professional II 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 an
• Appeals Professional II
• to support a contract with our federal client.

Performs complex work. Provides 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. Works under general supervision, with moderate latitude for the use of initiative and independent judgment. 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
• + Responsible for significant or complex programs, may assist with quality reviews and audits.

+ 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. + Stays abreast of changes in regulations, medical and healthcare practices, policies and procedures. + Participates in special projects and performs other duties as assigned. Requirements

• Required Skills and Experience
• + Three (3) years of medical dispute resolution or Medicare appeals, medical review, clinical, or related experience in a healthcare setting + Proficiency with research techniques, medical terminology, analyzing and interpreting policies, along with state and federal law and regulations + Must have experience and working knowledge of the Medicare program, including coverage and payment rules + Experience with Medicare regulations, claims administration, and medical review process, and applicable laws, rules, and regulations + Ability to prioritize and organize work assignments to multitask and meet deadlines + Ability to prepare correspondence/documents using correct spelling, grammar, and punctuation; proofreading and reviewing documents for clarity and consistency.

+ Exercise logic and reasoning to define problems, establish facts, and draw 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, preferred + Must have resided in the United States for a minimum of three (3) years out of the last five (5) years (Per Contract Requirement) + Ability to obtain and maintain Public Trust or equivalent security 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.
• Who We Are
• Tanaq Management 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 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 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 accommodation@tanaq.com.