Dispute Resolution Reviewer III
Performs complex (journey-level) 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.
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.
• Stays abreast of changes in regulations, medical and healthcare practices, policies and procedures.
• Participates in special projects and performs other duties as assigned.
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
o 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 setting
• Experience directly relevant to the specific task order or project, preferred
Appeals Professional I/Dispute Resolution Reviewer I/Case Analyst – October 2023
Knowledge, Skills and Abilities
Working knowledge of
• Research techniques
• Medical terminology
• Medicare program, including coverage and payment rules
• Medicare regulations, claims administration, and medical review processes
• Applicable laws, rules and regulations
Proficient skill in
• Preparing correspondence/documents using correct spelling, grammar and punctuation; proofreading and
reviewing documents for clarity and consistency
• Prioritizing and organizing work assignments
• Researching, analyzing and interpreting policies and state and federal laws and regulations
• The use of personal computers and applicable programs, applications and systems
Ability to
• Multitask and meet deadlines
• Exercise logic and reasoning to define problems, establish facts and draw valid conclusions
• Make decisions that support business objectives and goals
• 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
• Assures compliance with company policies, procedures, and guidelines including cybersecurity, regulatory,
Why J29?
J29 is an employee centric Federal Contractor that focuses on creating health and IT solutions for the better of the community. Making company culture the main priority ensures employees satisfaction and retention. We believe in empowering employees to do great things. When you invest in your people, and focus on creating a healthy work life balance, then your employees will take care of your customers and make sure they are happy. One of our sayings is “Work Hard and Be Nice to People” – it really is that simple.
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EEO Statement
J29, Inc. provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.
This policy applies to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation and training.