Medical Reviewer

• Maintain productivity, quality, and accuracy targets set by the Governmental Review Manager
• Promote compliance with regulatory standards through medical record review
• Collect, validate, and submit medical records for pre-claim reviews, ADR requests, and appeals
• Communicate documentation needs with agencies and follow up with agency leadership
• Audit medical record documentation for skilled home health, hospice, and PCS
• Communicate compliance findings and documentation deficiencies to management and patient-care personnel
• Identify visit documentation that lacks adequate content to support billing guidelines
• Help develop strategies and education to prevent revenue loss during recovery audits
• Assist with staff education tools and guides for clinical documentation and utilization
• Write business letters and reports explaining determinations and decisions to governmental payers, private insurers, and administrative law judges
• Participate in all levels of appeals using regulatory guidance and critical thinking
• Coordinate and evaluate operational systems to improve efficiency
• Provide leadership and support in identifying agency/client needs and improvement opportunities
• Report to the Supervisor Pre Claim Review