Medical Reviewer, Medicare
Job Description:
• Conducting pre- and post-payment medical reviews to ensure compliance with established clinical criteria and guidelines
• Review medically complex claims, pre-authorization requests, appeals, and fraud/abuse referrals
• Assess payment determinations using clinical information and established guidelines
• Evaluate medical necessity, appropriateness, and reasonableness for coverage and reimbursement
• Provide clear, well-documented rationales for service approvals or denials
• Educate internal and external teams on medical review processes, coverage determinations, and coding requirements
• Support quality control activities to meet corporate and team objectives
• Assist with special projects and additional responsibilities as assigned
Requirements:
• Active, unrestricted RN license in the U.S. and in the state of hire OR
• Active compact multistate RN license (as defined by the Nurse Licensure Compact)
• Associate Degree in Nursing OR
• Graduate of an accredited School of Nursing
• Two years of clinical experience plus at least two years in one of the following:
• Inpatient/Outpatient settings (i.e. medical-surgical, rehabilitation, SNF, etc..)
• Utilization/Medical Review
• Quality Assurance
• Strong clinical background in managed care and/or inpatient/outpatient settings
• Ability to interpret and apply medical review criteria and clinical guidelines
• Proficiency in Microsoft Office and word processing software
• Strong analytical, organizational, and decision-making skills
• Ability to work independently while managing priorities effectively
• Excellent customer service, communication, and critical thinking skills
• Ability to handle confidential information with discretion
Benefits:
• High-speed internet (non-satellite) and a private, lockable home office
• All necessary equipment to perform your job effectively, including but not limited to a desktop computer, dual monitors, a headset, an ethernet cable, and additional accessories as needed.
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• Conducting pre- and post-payment medical reviews to ensure compliance with established clinical criteria and guidelines
• Review medically complex claims, pre-authorization requests, appeals, and fraud/abuse referrals
• Assess payment determinations using clinical information and established guidelines
• Evaluate medical necessity, appropriateness, and reasonableness for coverage and reimbursement
• Provide clear, well-documented rationales for service approvals or denials
• Educate internal and external teams on medical review processes, coverage determinations, and coding requirements
• Support quality control activities to meet corporate and team objectives
• Assist with special projects and additional responsibilities as assigned
Requirements:
• Active, unrestricted RN license in the U.S. and in the state of hire OR
• Active compact multistate RN license (as defined by the Nurse Licensure Compact)
• Associate Degree in Nursing OR
• Graduate of an accredited School of Nursing
• Two years of clinical experience plus at least two years in one of the following:
• Inpatient/Outpatient settings (i.e. medical-surgical, rehabilitation, SNF, etc..)
• Utilization/Medical Review
• Quality Assurance
• Strong clinical background in managed care and/or inpatient/outpatient settings
• Ability to interpret and apply medical review criteria and clinical guidelines
• Proficiency in Microsoft Office and word processing software
• Strong analytical, organizational, and decision-making skills
• Ability to work independently while managing priorities effectively
• Excellent customer service, communication, and critical thinking skills
• Ability to handle confidential information with discretion
Benefits:
• High-speed internet (non-satellite) and a private, lockable home office
• All necessary equipment to perform your job effectively, including but not limited to a desktop computer, dual monitors, a headset, an ethernet cable, and additional accessories as needed.
Apply tot his job
Apply To this Job