Medical Reviewer

• Perform clinical decision-making and utilization management for clinically complex service and coverage requests
• Determine medical necessity and benefit coverage using applicable coverage documents, clinical guidelines and Medical Necessity Guidelines
• Ensure consistent and timely coverage decisions within product-specific compliance and regulatory timeframes
• Collaborate with Medical Directors on denial determinations and standard business processes
• Coach letter writers on appropriate medical necessity language for denial letters
• Communicate with physicians, practices, facilities, allied health providers and external customers regarding determinations and case status
• Orient new staff as needed
• Interface between Precertification staff and providers on policy interpretation, access availability and quality assurance issues
• Facilitate communication between Precertification and internal departments as a liaison or committee member
• Provide input to the Medical Policy Department and IMPAC medical systems
• Identify Utilization Management trends
• Assist in screening appeal cases and provide clinical input
• Model professionalism and leadership
• Perform other projects and duties as assigned

Medical Reviewer jobs in Massachusetts

Clinical Reviewer, Precertification RN