Medical Reviewer

• Perform medical claim reviews for medically complex services, preauthorization/predetermination requests, appeals or reconsiderations, potential fraud and/or abuse referrals, and correct coding
• Make payment determinations using clinical medical information and established criteria, protocol sets, or clinical guidelines
• Determine medical necessity, appropriateness, reasonableness, and coverage/reimbursement eligibility
• Monitor process timeliness according to contractor standards
• Document medical rationale supporting payment or denial of services and supplies
• Educate internal and external staff on medical reviews, terminology, coverage determinations, and coding procedures
• Participate in quality-control activities supporting corporate and team objectives
• Provide guidance, direction, and input to LPN team members
• Educate non-medical staff through discussions, team meetings, classroom participation, and feedback
• Assist with special projects and specialty duties assigned by management
• Complete six-week paid training, including one onsite week and five remote weeks

Medical Reviewer II

• Perform medical claim reviews for medically complex services, preauthorization/predetermination requests, appeals or reconsiderations, potential fraud and/or abuse referrals, and correct coding
• Make payment determinations based on clinical medical information and established criteria, protocols, or clinical guidelines
• Determine medical necessity, appropriateness, reasonableness, coverage, and reimbursement
• Monitor process timeliness according to contractor standards
• Document medical rationale supporting payment or denial of services and supplies
• Educate internal and external staff on medical reviews, medical terminology, coverage determinations, and coding procedures
• Participate in quality control activities supporting corporate and team objectives
• Provide guidance, direction, and input to LPN team members
• Educate non-medical staff through discussions, team meetings, classroom participation, and feedback
• Assist with special projects and specialty duties assigned by management