Simsy Ventures

Medical Reviewer

• 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

• Conduct comprehensive reviews of home health pre-claim review (PCR) packages to determine compliance with Medicare coverage, coding, and payment criteria
• Document affirmation/non-affirmation outcomes with well-defined clinical rationale in the designated case management system within 7 business days
• Engage with providers, as authorized, to request or clarify documentation
• Escalate provider concerns or suspected fraud in accordance with established program procedures
• Maintain 98% accuracy
• Complete required training, quality assurance reviews, and inter-rater reliability sessions

Medical Reviewer – 1099 Contract

• Conduct ESRD medical record reviews comparing medical record documentation to EQRS and NHSN to determine accuracy and timely reporting
• Determine and classify discrepancies based on the type and severity of errors, including missing data, incorrect values, and data entered in the wrong fields
• Participate in quality control activities to support corporate and team objectives
• Assist with special projects or responsibilities as assigned by management

Medical Claims Reviewer, 6 Month Contract

Technical Recruiter

• Consult with corporate leadership and the proposal team on qualifications needed for each position
• Post and maintain compelling job descriptions in Greenhouse (ATS)
• Use government contract proposal and award statement of work documents to develop and update job descriptions and specifications
• Use Boolean and advanced search techniques to source and identify top talent
• Screen and interview candidates
• Deliver world-class service to candidates and clients
• Obtain Letters of Intent (LOI) from qualified candidates for contract proposal efforts
• Coordinate with senior leadership and Business Development teams to review and determine top candidates
• Develop and maintain strong relationships with internal and external clients

Medical Reviewer

Medical Reviewer – 1099 Contract

Medical Claims Reviewer, 6 Month Contract

Senior Technical Recruiter