TMF Health Quality Institute

TMF Health Quality Institute   www.tmf.org   Please visit our Career Center to Apply and View the Full Job Description   https://jobs.tmf.org/   **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 in Louisiana or Texas *   Position Purpose: Plans, facilitates, and implements projects and ensures required deadlines and deliverables are met.   Essential Responsibilities: Develops, plans, creates, implements, analyzes, monitors, and distributes reports, logs, and other related documents, databases, and/or software within required timeframe and deadlines. Plans, implements, supports, and monitors activities needed to meet deliverables and activities for the project, including identifying issues, developing solutions, and continuously improving quality, processes, and efficiency. Develops, implements, updates, distributes, and maintains presentations, guides, and procedure documents, including education materials. Plans, organizes, and participates in meetings, trainings, seminars, events, and other related activities. Researches, gathers, interprets, analyzes, and ensures accuracy of data. Assists in researching and interpreting laws, regulations, and policies to assure compliance with regulatory and contractual entities to evaluate opportunities for change and improvements.     Minimum Qualifications   Education, License, Certification or Training Bachelor’s degree from an accredited college or university in healthcare administration or healthcare related discipline OR Registered Nurse (RN) Additional relevant experience in healthcare, project management, or other related areas may be substituted for Bachelor’s degree on a year per year basis. (Experience requirements may be satisfied by full-time experience or the prorated part-time equivalent.) Certified Professional in Healthcare Quality ( CPHQ ), preferred       Experience One (1) to Three (3) years relevant healthcare or project management Graduate or Professional degree in a health related discipline or other related field may be substituted for up to two (2) years of experience One (1) to Two (2) years process improvement, quality improvement, quality assurance, or related experience Recent experience working on healthcare quality improvement in Outpatient Clinic or nursing home or hospital setting, preferred     Benefits TMF 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  

TMF Health Quality Institute   www.tmf.org   Please visit our Career Center to Apply and View the Full Job Description   https://jobs.tmf.org/   **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.**    *Occasional overnight travel may be required*   Position Purpose: Performs advanced (senior-level) application development work and directs the work of others.  Directs and oversees the development, implementation, maintenance and modification of software and web applications and technical support.  Works independently with extensive latitude for the use of initiative and independent judgment.   Essential Responsibilities: Directs, plans, develops, implements, and oversees application development policies, procedures, and processes. Directs, plans and oversees the development, testing, debugging, deployment, and management of web and client/server applications, adhering to adopted software and development standards. Oversees project support in meeting the scope of project objectives, resource, time and budget allocation, expenditures, and financial reports. Oversees and ensures that clear specifications are created by effectively gathering and analyzing requirements for a new or modified solution. Oversees, directs, and provides support to users and staff and resolves issues as needed.     Minimum Qualifications   Education Bachelor's degree from an accredited college or university   Experience Ten (10) years developing and maintaining software and web applications Ten (10) years Structured Query Language (SQL) server Ten (10) years .NET Five (5) years leading system development projects Three (3) years management     Work Environment Requires working in an office/cubicle environment; sitting, standing, walking, bending, twisting and/or reaching. Requires repetitive movement; ability to lift, carry or move up to 25 lbs. when transporting work equipment or materials.  May require ability to operate a motor vehicle; the ability to travel by motor vehicle and commercial airline.  May require overnight travel.     Benefits TMF 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  

C2C INNOVATIVE SOLUTIONS https://www.c2cinc.com/   Please visit our Career Center to Apply and View the Full Job Description! https://jobs.tmf.org/   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, Anywhere US*   Position Purpose: Provides dissatisfied providers and/or suppliers the opportunity to present documentation or evidence to demonstrate why an appeal or rebuttal for an enrollment denial, revocation, or suspension should or should not be allowed. Provides an independent decision based on the documentation, facts, laws, regulations, and guidelines.   Essential Responsibilities: Reviews case file, writes a decision that is clear, concise, and impartial and supports the decision made. Makes sound, independent decisions based on evidence in accordance with statutes, regulation, rulings, and policy. Acts as internal consultant by providing guidance and support to assist Appeals specialist, Project Manager, and QA Manager in the development of written decisions.   Provides high quality customer service to all providers/suppliers/properly appointed representatives as it relates to the submission, processing, and issuance of decisions.   Conducts research using online federal regulations, policy, and other related resources to complete an accurate and well-supported decision.     Minimum Qualifications   Education and Experience (Per Contract Requirements) Bachelor’s degree from an accredited college or university and Three (3) years experience in healthcare regulatory interpretation/application and/or healthcare compliance OR Paralegal Certificate from an accredited institution and Three (3) years experience working as a paralegal OR Licensed attorney with at least one (1) year of experience in healthcare regulatory interpretation/application United States resident for a minimum of three (3) years out of the last five (5) years (Per Contract Requirement) Medicare, preferred Legal writing experience, preferred     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  

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 in Jacksonville, FL*   Position Purpose: Performs entry level clerical work.  Assists the mailroom in meeting goals in support of the contracts and company processes.  Works under close supervision, with minimal latitude for the use of initiative and independent judgement.    Essential Responsibilities: Receives and processes (check-in) incoming mail. Properly identifies and prepares mail receipts for scanning. Performs imaging and indexing activities as required. Enters data (key/type) into internal systems. Delivers mail to internal customers as needed. Meets production, quality, and behavioral standards to assist the mailroom in meeting goals. Prints, folds, stuffs, and mails letters.     Minimum Qualifications   Education High School Diploma or equivalent   Experience Six (6) months of work experience College education or technical training in business related areas may be substituted for experience on a month per month basis. (Education requirements may be satisfied by full-time education or the prorated part-time equivalent.) United States resident 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  

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 in Jacksonville, FL US* *This position requires a credit check*     Position Purpose: Provides lead work and subject matter expertise through technical support and one-on-one training. Computes, classifies, records and maintains numerical data in accordance with regulations, policies and procedures to keep financial records complete and provides general office duties.  Ensures the completeness of the dispute before it goes to a Dispute Resolution Reviewer (DRR) decision-maker, including, but not limited to, confirming the administrative fee has been received and accepted, prior to passing the dispute to the DRR for resolution.    Essential Responsibilities: Serves as a lead staff member and subject matter expert for the Dispute Resolution Analysts and/or Clerks. Reviews documentation and communicates with insurance carriers and providers as needed. Reviews and analyzes medical billings for appropriate payment classifications. Uses subject-matter knowledge and judgment related to pricing disputes to resolve processing issues. Accesses electronic financial payment information to answer general questions as well as those related to specific accounts. Assists with questions related to the contract or project. This may include, but is not limited to, corrections and detailed explanations as to how to properly comply with Centers for Medicare & Medicaid Services (CMS) guidelines.       Minimum Qualifications   Education High School diploma or equivalent   Experience Four (4) years general office experience College education or technical training in administration, business, or related areas may be substituted for experience on a year per year basis. (Education requirements may be satisfied by full-time education or the prorated part-time equivalent.) General accounting, preferred Healthcare Industry, preferred       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  

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, Anywhere US*     Position Purpose: Serves as a support person for the reconsideration/dispute resolution professionals and physician reviewers for second level reconsiderations/dispute resolutions.   Essential Responsibilities: Coordinates the delivery of re-determination files/dispute resolution documents and reconsideration/dispute resolution decisions from and to the external entities. Builds a reconsideration/dispute resolution case file from evidence submitted and received and analyzes each case to ensure it meets the requirements for a valid reconsideration/dispute resolution request as mandated by Centers for Medicare and Medicaid Services (CMS) or other customer entities. Analyzes and makes decisions based on medical vs. non-medical case type, appeal/review categories, validity of appeal/dispute resolution request, and dispute resolution settlement documentation. Inputs appropriate data regarding reconsiderations/dispute resolution cases into the applicable required systems. Responds to reconsideration/dispute review requests from appellants/patients/providers.     Minimum Qualifications   Education High School Diploma or equivalent   Experience One (1) year of general office experience College education or technical training in administration, business, or related areas may be substituted for experience on a year per year basis. (Education requirements may be satisfied by full-time education or the prorated part-time equivalent.) Independent Dispute Resolution (IDR), preferred   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  

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 Anywhere US*     Position Purpose: Performs complex (journey-level) quality audit work.  Audits second level appeals of claims to ensure compliance with contract requirements and performs user testing and interface with the required systems.   Works under general supervision, with moderate latitude for the use of initiative and independent judgement.    Essential Responsibilities: Performs audits and examinations of case files to identify inaccuracies and non-compliance issues. Shares educational feedback, trends and insight individually and collectively with the staff. Performs data analysis to identify improvement opportunities in the appeals process and reduce unnecessary appeals. Provides quality and analytical support to the department including assisting senior analyst in data interpretation and preliminary analysis. Prepares training materials and provides technical training to employees.     Minimum Qualifications   Education High School Diploma or equivalent   Experience Three (3) years of general office experience College education or technical training in administration, business, or related areas may be substituted for experience on a year per year basis. (Education requirements may be satisfied by full-time education or the prorated part-time equivalent.) One (1) year of dispute resolution experience or other healthcare appeals processes Quality, preferred Dispute resolution experience, preferred       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  

TMF Health Quality Institute   www.tmf.org   Please visit our Career Center to Apply and View the Full Job Description   https://jobs.tmf.org/   **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 in Austin, Texas and utilizes a hybrid schedule*     Position Purpose: Performs complex (journey-level) accounting work.  Maintains general ledger and prepares financial reports; researches, prepares, analyzes and interprets financial data; and supports audit activities.  Works under moderate supervision, with moderate latitude for the use of initiative and independent judgement.    Essential Responsibilities: Provides accounts payable, expense reimbursement and cash disbursement support, guidance, research and coordination to all departments on contract-related issues, requests for proposals, and statutory, regulatory, and agency requirements. Prepares payroll related reports and journal entries, quarterly tax returns and reconciliations. Prepares monthly customer invoicing, reconciling to contracts, revenue accruals and progress reporting. Prepares monthly reports, including those that compare budgeted revenues and expenses to actual. Prepares, examines, and analyzes accounting records, financial statements, and other financial reports to assess accuracy, completeness, and conformance to reporting and procedural standards. Complies requests made by the external auditors for information needed to complete the audit.     Minimum Qualifications   Education Bachelor's degree from an accredited college or university in accounting or finance Additional experience in accounting or other related areas may be substituted for Bachelor’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 accounting Education towards a Master’s Degree in accounting or finance or a Master’s Degree in accounting or finance may be substituted for experience on a year per year basis. (Education requirements may be satisfied by full-time education or the prorated part-time equivalent.)     Work Environment Requires working in an office/cubicle environment; sitting, standing, walking, bending, twisting and/or reaching. Requires repetitive movement; ability to lift, carry or move up to 25 lbs. when transporting work equipment or materials.  May require ability to operate a motor vehicle; the ability to travel by motor vehicle and commercial airline.  May require overnight travel.     Benefits TMF 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

TMF Health Quality Institute   www.tmf.org   Please visit our Career Center to Apply and View the Full Job Description   https://jobs.tmf.org/   **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, Texas*     Position Purpose: Performs moderately complex or complex (journey or senior level) work.  Conducts contract activities in accordance with state agencies and the state policies and requirements.  Works under general supervision, with moderate latitude for the use of initiative and independent judgment.                                                                                                                                      Essential Responsibilities: Obtains, reviews, and may organize and analyze medical records to determine compliance with review and program policies. Documents review findings and recommends adjustments or denials of services for each claim detail. Obtains physician/dentist decisions on medical necessity-related findings. Composes narrative summary of record review findings and writes education or recoupment letters as directed. Works with State customer on review findings. Performs actions for case disposition which may include, but is not limited to, assisting in conducting provider education and may perform prepayment review and adjudicating claims based on results of record review Documents and tracks provider case review activities, case dispositions, and may perform prepayment review activities. Performs reviews of cases referred from state agencies and prepares report of findings.     Minimum Qualifications   Education Diploma Nurse or Associates degree in nursing or related discipline from an accredited college or university   License and Certification Registered Nurse (RN) with an active Texas license Coding Certification, preferred   Experience Three (3) to four (4) years healthcare Two (2) years clinical in a healthcare setting One (1) to two (2) years utilization management, retrospective review, medical record review, or claims review Surveillance and Utilization Review (SUR), preferred     Benefits TMF 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 Minorities/Females/Vet/Disability

C2C INNOVATIVE SOLUTIONS https://www.c2cinc.com/   Please visit our Career Center to Apply and View the Full Job Description! https://jobs.tmf.org/   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 Anywhere US*     Position Purpose: Performs complex (senior-level) work.  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.   Works under general supervision, with moderate latitude for the use of initiative and independent judgment.   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.     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 demonstrated experience writing or making medical necessity decisions Nursing, Physical Therapy, Respiratory Therapy or Occupational Therapy experience Medicare Experience       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 Minorities/Females/Vet/Disability  

TMF Health Quality Institute   www.tmf.org   Please visit our Career Center to Apply and View the Full Job Description   https://jobs.tmf.org/   **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 in Austin, Texas OR Jacksonville, FL OR Remote, Anywhere US*   Position Purpose: Performs highly complex (senior-level) work.  Implements, upgrades, and monitors security measures for the protection of the Information Technology networks, systems and information, and acts as a first line responder to security events and incidents.  Works under limited supervision, with moderate latitude for the use of initiative and independent judgement.    Essential Responsibilities: Manages vulnerability management program using Rapid7 InsightVM, maintains security baselines using CIS Workbench, and performs compliance scanning with CIS CAT-Pro. Duties include performing scans, maintenance of the platform, analysis of vulnerabilities for criticality and devising and implementing remediations. Manages and analyzes output from various security tools to include, but not limited to: Vulnerability Management, EDR/XDR, SEIM/SOAR, Email Security Gateway, and WAF. Plans and performs technical analysis with a variety of Information Security tools and techniques to identify, analyze and resolve security threats, vulnerabilities, events, and incidents. Creates and tunes alerts and configurations. Consults and works with internal and external stakeholders to remediate or mitigate security vulnerabilities, events, and incidents .   Minimum Qualifications   Education Bachelor's degree from an accredited college or university  Additional experience in an information technology system and network role or other related areas may be substituted for Bachelor’s degree on a year per year basis. (Experience requirements may be satisfied by full-time experience or the prorated part-time equivalent.) Certification Professional security certification, such as GIAC Security Essentials Certification (GSEC), Systems Security Certified Practitioner (SSCP), Certified Information Security Systems Professional (CISSP), CompTIA CYSA+, or CompTIA SecurityX (Formerly CASP+)   Experience Three (3) years in an information technology systems and network or related role Three (3) years in information security or support of an information security     Benefits TMF 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 Minorities/Females/Vet/Disability  

**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 in Austin, Texas OR Remote, Anywhere US* *This position requires a credit check*     Position Purpose: Performs advanced (senior-level) information security work. Provides a variety of operational, compliance, and consultative functions. Manages the delivery of information security systems, software and services, facilities security, and HIPAA Privacy & Security.  Leads a team of information security employees and is responsible for providing the organization thought leadership on information security operations and control of security events and incidents.  Works under minimal supervision, with considerable latitude for the use of initiative and independent judgement.    Essential Responsibilities: Plans, sets direction, manages, and provides critical support in the strategic and tactical planning for the design, implementation and use of cyber security technology, to include ongoing budget management and planning. Oversees and implements new systems, services, procedures and techniques. In coordination with the CISO, develops strategy for, builds and maintains highly functioning programs for security monitoring, vulnerability management, identity and access management, endpoint security, network security and application security. Manages, develops, updates, implements, and enforces security policies and procedures. Manages processes, Service Level Agreements, and relationships with outsourced security service providers.     Minimum Qualifications   Education Bachelor's degree from an accredited college or university     Certification Professional Security certification, such as CISSP, CCNA Security, CISM Certified Information Systems Security Professional (CISSP), preferred   Experience Five (5) years in an Information Security operations related role Two (2) years management or supervisory Two (2) years in managing and developing Information Security technology and/or other technology teams Experience leading projects Experience in production support Experience handling large volume of incident and service request tickets       Benefits TMF 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 Minorities/Females/Vet/Disability  

C2C INNOVATIVE SOLUTIONS https://www.c2cinc.com/   Please visit our Career Center to Apply and View the Full Job Description! https://jobs.tmf.org/   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 Anywhere US*     Position Purpose: Performs highly complex (journey-level) business application work. Responsible for overseeing the development of software products using the Agile Methodology. Works under minimal supervision, with considerable latitude for the use of initiative and independent judgement.    Essential Responsibilities: Designs, develops, and deploys applications using low-code/no-code platforms, such as Mendix, OutSystems, Appian, or Creatio. Collaborates with business stakeholders and clients to gather requirements and translate them into technical specifications. Quickly iterates on application prototypes based on user feedback. Establishes implementation capabilities and limitations, performance requirements, and interfaces for the end-user solution. Delivers efficient solutions using low-code by analyzing business, systems, and workflow processes and developing solutions that meet customers' needs. Educates users in understanding and effectively utilizing low-code/no-code solutions. Researches, analyzes, and develops solutions quickly, focusing on process automation and optimization.     Minimum Qualifications   Education Bachelor’s degree from an accredited college with a major in computer science, engineering or a related discipline Additional experience in software project management, software development or other related areas may be substituted for a Bachelor’s degree on a year-per-year basis. (Experience requirements may be satisfied by full-time experience or the prorated part-time equivalent.)     Experience Five (5) years in software project management or development Two (2) years of support in software and problem diagnosis One (1) year low-code/no-code application development Basic SQL, HTML, CSS, JavaScript, and general Web 2.0 techniques experience Experience with commonly used low-code/no-code platforms such as Mendix, OutSystems, Appian, or Creatio Leading, planning, and working with customers on technical software implementation and integration processes and activities       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 Minorities/Females/Vet/Disability  

C2C INNOVATIVE SOLUTIONS https://www.c2cinc.com/   Please visit our Career Center to Apply and View the Full Job Description! https://jobs.tmf.org/   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 Anywhere US*   Position Purpose: Performs complex (journey-level) work.  Provides dissatisfied providers and/or suppliers the opportunity to present documentation or evidence to demonstrate why an appeal or rebuttal for an enrollment denial, revocation, or suspension should or should not be allowed. Provides an independent decision 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 case file, writes a decision that is clear, concise, and impartial and supports the decision made. Makes sound, independent decisions based on evidence in accordance with statutes, regulation, rulings, and policy. Acts as internal consultant by providing guidance and support to assist Appeals specialist, Project Manager, and QA Manager in the development of written decisions.   Provides high quality customer service to all providers/suppliers/properly appointed representatives as it relates to the submission, processing, and issuance of decisions.       Minimum Qualifications   Education and Experience (Per Contract Requirements) Bachelor’s degree from an accredited college or university and Three (3) years experience in healthcare regulatory interpretation/application and/or healthcare compliance OR Paralegal Certificate from an accredited institution and Three (3) years experience working as a paralegal Legal writing experience, preferred     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 Minorities/Females/Vet/Disability  

C2C INNOVATIVE SOLUTIONS https://www.c2cinc.com/   Please visit our Career Center to Apply and View the Full Job Description! https://jobs.tmf.org/   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 Anywhere US*     Position Purpose: Performs complex (journey-level) quality audit work.  Audits second level appeals of claims to ensure compliance with contract requirements and performs user testing and interface with the required systems.   Works under general supervision, with moderate latitude for the use of initiative and independent judgement.    Essential Responsibilities: Performs audits and examinations of case files to identify inaccuracies and non-compliance issues. Shares educational feedback, trends and insight individually and collectively with the staff. Performs data analysis to identify improvement opportunities in the appeals process and reduce unnecessary appeals. Provides quality and analytical support to the department including assisting senior analyst in data interpretation and preliminary analysis. Prepares training materials and provides technical training to employees.     Minimum Qualifications   Education High School Diploma or equivalent   Experience Three (3) years of general office experience College education or technical training in administration, business, or related areas may be substituted for experience on a year per year basis. (Education requirements may be satisfied by full-time education or the prorated part-time equivalent.) One (1) year of dispute resolution experience or other healthcare appeals processes Quality, preferred Dispute resolution experience, preferred       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 Minorities/Females/Vet/Disability  

C2C INNOVATIVE SOLUTIONS https://www.c2cinc.com/   Please visit our Career Center to Apply and View the Full Job Description! https://jobs.tmf.org/   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 Anywhere US*     Position Purpose: Performs advanced (senior-level) quality assurance work.  Ensures decision makers adjudicate cases accurately by performing quality audits, reviews, and publishing audit results and conducting meetings, providing coaching, and training on quality.  Works under limited supervision, with considerable latitude for the use of initiative and independent judgement.    Essential Responsibilities: Performs audits to ensure timeliness, accuracy, and consistency in reconsideration/dispute resolution decisions. Participates in planning, preparing, and facilitating discussion for regularly scheduled process and program improvement meetings. Oversees, provides and plans training for new and current staff, including developing and presenting presentations, quality tips, and decision consistency memos. 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 Additional Medicare appeals or clinical 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 medical dispute, Medicare appeals or clinical experience in a healthcare setting Two (2) years of training Quality experience Healthcare Professional with demonstrated experience writing or making medical necessity decisions Nursing, Physical Therapy, Respiratory Therapy or Occupational Therapy experience     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 Minorities/Females/Vet/Disability  

C2C INNOVATIVE SOLUTIONS https://www.c2cinc.com/   Please visit our Career Center to Apply and View the Full Job Description! https://jobs.tmf.org/   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 Anywhere US*     Position Purpose: Performs complex (senior-level) work.  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.   Works under general supervision, with moderate latitude for the use of initiative and independent judgment.   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.     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 demonstrated experience writing or making medical necessity decisions Nursing, Physical Therapy, Respiratory Therapy or Occupational Therapy experience Medical billing, medical appeals or clinical Patient- Provider Dispute Resolution, preferred Independent Dispute Resolution, preferred Coding certificate, preferred       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 Minorities/Females/Vet/Disability  

C2C INNOVATIVE SOLUTIONS https://www.c2cinc.com/   Please visit our Career Center to Apply and View the Full Job Description! https://jobs.tmf.org/   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 Anywhere US*     Position Purpose: 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.     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 One (1) year of Medicare appeals, medical review, clinical, healthcare regulatory interpretation/application, healthcare compliance or related experience in a healthcare setting Appeals and Billing, preferred Coding Certificate, preferred     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 Minorities/Females/Vet/Disability  

C2C INNOVATIVE SOLUTIONS https://www.c2cinc.com/   Please visit our Career Center to Apply and View the Full Job Description! https://jobs.tmf.org/   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 Anywhere US*     Position Purpose: Performs complex (senior-level) work.  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.   Works under general supervision, with moderate latitude for the use of initiative and independent judgment.   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.     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 demonstrated experience writing or making medical necessity decisions Nursing, Physical Therapy, Respiratory Therapy or Occupational Therapy experience Medicare Experience         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 Minorities/Females/Vet/Disability

TMF Health Quality Institute   www.tmf.org   Please visit our Career Center to Apply and View the Full Job Description   https://jobs.tmf.org/   **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, Texas* *This position is Part Time (PRN)*     Position Purpose: Performs moderately complex (journey-level) quality assurance work.  Plans and facilitates projects and ensures required deadlines and deliverables are met. Travels across Texas and completes Vaccines for Children site visits in a timely manner before their due date. Works under general supervision, with moderate latitude for the use of initiative and independent judgement.    Essential Responsibilities: Completes Vaccines for Children and Adult Safety Net visits as assigned, in provider offices during core business hours (Monday-Friday, 8am-5pm). Enters documentation of visits into appropriate databases by deadlines established. Educates providers on key areas where they are deficient to assist in compliance with program requirements. Travels (drives) to various areas of Texas as assigned to complete site visits, including both day and overnight travel (up to a week at a time). Maintains communication and feedback necessary for program performance.     Minimum Qualifications   Education High School Diploma or equivalent     Experience Four (4) years reviewing medical records College education or technical training in social services, public health, or related areas may be substituted for experience on a year per year basis. (Education requirements may be satisfied by full-time education or the prorated part-time equivalent.) Ability to travel daily, with up to 80% of the time being overnight travel Ability to work during core business hours (Monday-Friday, 8am to 5pm)         EOE Minorities/Females/Vet/Disability