Medical Reviewer

• Assess the medical necessity and quality of healthcare services through prospective, concurrent, and retrospective utilization management reviews
• Apply clinical review criteria, organizational policies, guidelines, and InterQual screening tools
• Consult physician/practitioner consultants when services do not meet medical necessity criteria
• Collaborate with internal teams and refer cases for additional review or escalation
• Refer cases to management when required
• Provide clinical and utilization review subject matter expertise
• Respond to provider, customer, and stakeholder questions regarding determinations and processes
• Conduct outreach to providers, case managers, consultants, and community support coordinators to obtain additional clinical information
• Maintain accurate documentation and comply with regulatory and contract standards
• Support high-quality, appropriate, and cost-effective care while ensuring compliance with clinical criteria, organizational policies, and Alaska-specific contract requirements
• Work remotely in a home-based setting using computers, phones, and virtual communication tools
• Occasional travel for meetings, training, or work-related events may be required

Medical Reviewer jobs in Alaska

Clinical Reviewer