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

• 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

• Lead scheduled and ad hoc peer-to-peer discussions with treating physicians and other qualified providers regarding inpatient, outpatient, post-acute, and other authorization requests
• Analyze member clinical documentation, utilization management reviews, applicable criteria, and rationale before peer-to-peer discussions
• Evaluate medical necessity and level of care, including inpatient versus observation/outpatient status
• Apply CMS Medicare Advantage requirements, the Two-Midnight benchmark, NCDs/LCDs, MCG or other approved clinical criteria, and health plan policies
• Discuss clinical rationales professionally with treating providers
• Consider new clinical information and adjust medical necessity determinations or overturn proposed adverse determinations when supported and within delegated authority
• Document peer-to-peer discussions, clinical details, participants, outcomes, and rationale within required regulatory and organizational turnaround times
• Maintain strict HIPAA compliance
• Escalate complex, high-risk, or unclear cases to Medical Directors or clinical leadership
• Lead case review discussions on clinical Joint Operating Committees
• Identify recurring clinical, documentation, or provider-education opportunities and communicate trends to utilization management leadership

Physician Advisor – Peer-to-Peer Medical Reviewer

• 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

• Conduct independent clinical reviews of healthcare claims and supporting medical documentation
• Review medical records, treatment plans, clinical notes, diagnostic testing, imaging, procedure documentation, and relevant clinical information
• Evaluate services for medical necessity, clinical appropriateness, and consistency with accepted standards of medical practice
• Assess whether documentation supports billed services, procedures, diagnoses, and level of care
• Apply Medicaid policies, coverage requirements, clinical criteria, and review guidelines
• Identify potentially unnecessary, excessive, duplicative, unsupported, or questionable services
• Develop objective, evidence-based clinical determinations and document review rationales
• Respond to clarification or additional clinical-analysis requests
• Escalate complex clinical or policy questions and participate in clinical discussions
• Maintain consistency, accuracy, and objectivity across assigned reviews
• Meet quality, productivity, and project timelines
• Maintain confidentiality and security of protected health information and comply with HIPAA and data-security requirements

Medical Clinical Reviewer, MD/DO

• Conduct comprehensive reviews of clinical cases
• Apply specialized otolaryngology expertise to provide objective, evidence-based medical advisory opinions
• Review medical records, clinical documentation, diagnostic reports, and treatment records
• Prepare clear and concise clinical summaries
• Respond to client questions related to otolaryngologic care
• Perform advisory medical record reviews only, without peer-to-peer discussions, calls, or direct patient care
• Evaluate ENT procedures, treatment, medical records, and clinical documentation
• Provide high-quality, objective, and defensible medical determinations

Board-Certified Otolaryngologist – Clinical Reviewer

• Conduct comprehensive reviews of dental and medical records, treatment documentation, diagnostic information, and clinical records
• Prepare clear and concise clinical summaries
• Respond to specific client questions related to dental care
• Provide objective, evidence-based medical advisory opinions
• Perform advisory medical record reviews only, without peer-to-peer discussions, calls, or direct patient care
• Support high-quality, objective, and defensible medical determinations

Licensed Dentist – Clinical Reviewer

• Provide utilization management activities for members in inpatient settings
• Apply industry-standard and plan-proprietary criteria to determine appropriateness of inpatient and post-acute settings on initial and concurrent reviews
• Determine reimbursement methodology and schedule concurrent reviews
• Review inpatient admissions and continued stays for length of stay, medical necessity, and discharge planning
• Identify and determine medical necessity for out-of-network requests
• Perform discharge planning for acute and post-acute admissions
• Identify complex members and refer them to case management or disease management programs
• Redirect members and providers to in-network or preferred providers
• Identify potential High Risk High Needs members and present them at Consultive Rounds
• Conduct preauthorization of transplant requests as required
• Complete case documentation, daily tasks, UM event management, and same-day case data entry
• Mentor new and existing staff on process and system changes
• Facilitate UM/CM Consultive Rounds
• Serve as a subject matter expert supporting Inpatient Management initiatives and systems including MedHOK, Case Trakker, and Jiva
• Assist the Team Manager with day-to-day team activities and assignments
• Develop collaborative relationships with partner departments and key customers
• Prepare cases for and participate in weekly UM/CM Consultive Rounds
• Participate in committees or serve as team liaison as needed
• Maintain professional growth and development
• Perform additional related duties as assigned

Clinical Reviewer, Inpatient RN

• Conduct scheduled and ad hoc peer-to-peer discussions with treating physicians and other qualified providers regarding inpatient, outpatient, post-acute, and other authorization requests
• Review members' clinical documentation, utilization management review, applicable criteria, and rationale for proposed or issued determinations
• Evaluate medical necessity and the appropriate level of care, including inpatient versus observation/outpatient status
• Apply CMS Medicare Advantage requirements, the Two-Midnight benchmark, applicable NCDs/LCDs, MCG or other approved clinical criteria, and health plan policies
• Discuss clinical rationale for determinations with treating providers
• Consider additional clinical information and determine whether it changes the medical necessity determination
• Approve or overturn proposed adverse determinations when supported by new information, within delegated authority and organizational policy
• Escalate complex, high-risk, or unclear cases to Medical Directors or clinical leadership
• Document P2P discussions accurately and contemporaneously
• Complete P2P requests within regulatory and organizational turnaround times
• Identify recurring clinical, documentation, criteria, or provider-education opportunities and communicate trends to UM leadership
• Collaborate with nurses, medical directors, appeals and grievances, provider engagement, and other operational teams
• Maintain confidentiality and comply with HIPAA, CMS, accreditation, and organizational requirements
• Lead case review discussions on clinical JOCs

Medical Reviewer jobs in United States