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Dispute Resolution Reviewer III (Healthcare Professional)

TMF Health Quality Institute -
Remote

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Job Details

Full-time

Benefits

License reimbursement
AD&D insurance
Disability insurance
Health insurance
Dental insurance
401(k)
Tuition reimbursement
Vision insurance
Life insurance

Qualifications

Research

Full Job Description

Category: Program Management

Requisition Number: DRRII001384

Posting Details

- Posted: June 4, 2026
Full-Time
Locations

Remote, Anywhere USA

Job Details

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 United States*

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
Independent Dispute Resolution, preferred
Resided in the United States for a minimum of three (3) years out of the last five (5) years (Per Contract Requirement)

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.

Apply Now

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