Reviewer I, Medical
About the position The Reviewer I, Medical position at US Tech Solutions involves performing medical reviews and utilization management for professional, inpatient, or outpatient services. The role requires strong communication skills and the ability to work independently while being detail-oriented and organized. Initially, the position is onsite for training, after which it transitions to a fully remote role. The primary responsibilities include reviewing medical claims, determining eligibility and medical necessity, and providing education to members and providers. Responsibilities • Performs medical reviews using established criteria sets and/or performs utilization management of professional, inpatient or outpatient, facility benefits or services, and appeals. • Documents decisions using indicated protocol sets or clinical guidelines. • Provides support and review of medical claims and utilization practices. • Performs medical claim reviews and makes reasonable charge payment determinations. • Monitors process's timeliness in accordance with contractor standards. • Performs authorization processes, ensuring coverage for appropriate medical services within benefit and medical necessity guidelines. • Utilizes allocated resources to back up review determinations. • Reviews interdepartmental requests and medical information in a timely/effective manner to complete utilization processes. • Conducts high dollar forecasting research and formulates overall patient health summaries with future health prognosis and projected medical costs. • Performs screenings/assessments and determines risk via telephone. • Reviews/determines eligibility, level of benefits, and medical necessity of services and/or reasonableness and necessity of services. • Provides education to members and their families/caregivers. • Reviews first level appeals and ensures thorough documentation of each determination and basis for each. • Conducts necessary research to make thorough/accurate determinations. • Educates internal/external staff regarding medical reviews, medical terminology, coverage determinations, coding procedures, etc. • Responds accurately and timely with appropriate documentation to members and providers on all rendered determinations. • Participates in quality control activities in support of corporate and team-based objectives. • Participates in all required training. Requirements • 2 years clinical experience. • Active, unrestricted LPN/LVN licensure from the United States and in the state of hire, OR, active compact multistate unrestricted LPN license as defined by the Nurse Licensure Compact (NLC), OR, active, unrestricted LBSW (Licensed Bachelor of Social Work) licensure from the United States and in the state of hire. • Working knowledge of word processing software. • Good judgment skills. • Demonstrated customer service and organizational skills. • Demonstrated proficiency in spelling, punctuation, and grammar skills. • Analytical or critical thinking skills. • Ability to handle confidential or sensitive information with discretion. • Ability to remain in a stationary position and operate a computer. Nice-to-haves • Working knowledge of spreadsheet and database software. • Demonstrated oral and written communication skills. • Ability to persuade, negotiate, or influence others. Apply tot his job