Reviewer

• Support the Credit Risk Review team in leading continuous quarterly credit file examination activities
• Process loan review engagements
• Execute quarterly analyses of credit quality trends for assigned loan portfolios or risk segments
• Evaluate commercial loan transactions and assess underwriting and portfolio management
• Provide independent feedback on underwriting analyses, risk grading decisions, credit mitigation actions, and credit management controls
• Monitor credit risk trends within assigned commercial lending risk segments
• Attend relevant meetings and maintain relationships with internal credit approval and portfolio management stakeholders
• Review credit and financial information, including financial statements, spreadsheets, cash flow analyses, and other sources
• Assess borrower risk profiles and risk grades, including complex lending relationships
• Perform risk-based sampling for continuous and periodic file reviews and adjust examination scope as appropriate
• Guide less experienced reviewers
• Analyze loan reporting and tracking systems and prepare comments for Credit Risk Review reports
• Evaluate changes or weaknesses in Credit Administration processes and policies
• Maintain knowledge of specialty NDFI lending industries
• Apply regulatory requirements, enterprise-wide Credit Policy, and Credit Risk Review policies and procedures
• Assist with ad hoc special projects
• Report to a Credit Risk Review Director, Senior Manager, or Manager

Credit Risk Reviewer

• Review and audit clinical data submitted to the STS Congenital Heart Surgery Database against source medical record documentation
• Validate case selection, procedure coding, outcomes, and registry variables for completeness and accuracy
• Identify and document matches, mismatches, and potential data quality concerns using HMS audit tools
• Review operative reports, progress notes, diagnostic studies, discharge summaries, and other relevant medical records
• Participate in initial and ongoing reviewer training activities
• Meet established productivity, quality, and inter-rater reliability standards
• Escalate questions regarding data definitions, documentation interpretation, or audit findings through established channels
• Participate in adjudication activities and documentation review when sites respond to preliminary audit findings
• Provide clear, professional documentation regarding audit determinations and supporting rationale
• Maintain confidentiality and comply with HMS security, privacy, and data protection requirements
• Participate in team meetings and project calls as needed
• Perform other duties as assigned

Congenital Heart Surgery Database Reviewer

• Review outpatient coded cases for coding completeness and accuracy
• Identify potential coding and APC/payment opportunities
• Research appropriate guidelines to support recommended changes
• Communicate coding changes to coders or quality reviewers in a timely manner
• Provide expert coding advice to coding staff and global quality reviewers
• Relay needed coding education topics to the Manager of Outpatient Coding Quality
• Conduct quality reviews of outpatient records and validate CPT®, HCPCS, ICD-10-CM, modifier, and APC code assignments
• Provide audit feedback, coaching, and guidance
• Analyze audit results and identify trends for education, process improvement, and quality enhancement
• Partner with Quality, Education, Denials, and Coding Operations teams to resolve coding issues and support revenue integrity initiatives
• Stay current on industry regulations and coding guidelines
• Drive continuous improvement through collaboration, training, and process optimization while maintaining accuracy, productivity, and performance in a remote environment

Outpatient Quality Reviewer

• Conduct clinical reviews of behavioral health service requests, claims, and appeals
• Review pre-authorization requests, concurrent reviews, and retrospective behavioral health claims
• Apply InterQual and medical policy criteria to document medical necessity
• Refer cases not meeting criteria to the Psychiatric Medical Director for secondary review
• Support the appeals department in reviewing provider and member appeals within regulatory timelines
• Interact with behavioral health care providers regarding level-of-care and service decisions
• Document clinical decisions and rationale in the utilization management system
• Communicate determinations to providers and members by phone and written correspondence
• Analyze behavioral health member data to improve quality and appropriate service utilization
• Collaborate with Case Management, Quality, Provider Relations, and other internal departments
• Maintain compliance with CMS, NCQA, URAC, and other state, federal, and accreditation requirements
• Participate in audits, training, and quality-improvement initiatives
• Perform other job-related duties within the scope of responsibilities

Behavioral Health Utilization Reviewer

• Perform clinical review and validation of OASIS assessments for contracted home health agency clients
• Use Mosai’s AI-assisted review platform and client electronic medical records to independently verify platform-generated findings
• Review OASIS assessments at Start of Care, Resumption of Care, Recertification, Transfer, and Discharge
• Validate OASIS responses against the current OASIS data set, CMS Guidance Manual, skip logic, and CMS Quarterly OASIS Q&As
• Verify internal consistency between OASIS responses and supporting records, especially Section GG, cognitive and behavioral items, and case-mix-impacting M-items
• Apply PDGM requirements, including clinical grouping, functional impairment level, comorbidity adjustment, and LUPA exposure
• Review ICD-10-CM diagnosis assignment and sequencing where credentialed, as a secondary scope
• Escalate coding or OASIS conflicts to Mosai clinical operations
• Produce written, compliant, non-leading recommendations with supporting documentation, applicable guidance, and clinical rationale
• Enter recommendations through client-defined channels, meet turnaround commitments, and track recommendations to closure
• Work across multiple client agencies and EMR platforms
• Access protected health information according to HIPAA minimum necessary requirements and applicable Business Associate Agreements
• Maintain review accuracy at or above Mosai clinical quality standards
• Participate in calibration exercises
• Report platform false positives, missed findings, and outdated guidance references
• Perform production review work that is not client-facing; route questions and escalations through clinical operations and client services

Reviewer – Home Health

• Perform clinical review and validation of OASIS assessments for contracted home health agency clients
• Use Mosai’s AI-assisted review platform and client electronic medical records
• Independently verify every platform-generated finding against source documentation
• Review OASIS assessments at Start of Care, Resumption of Care, Recertification, Transfer, and Discharge
• Validate responses against the current OASIS data set, CMS Guidance Manual, applicable skip logic, and CMS Quarterly OASIS Q&As
• Check internal consistency of OASIS responses and supporting records, especially Section GG, cognitive and behavioral items, and case-mix-impacting M-items
• Apply PDGM requirements, including clinical grouping, functional impairment level, comorbidity adjustment, and LUPA exposure
• Review ICD-10-CM diagnosis assignments against official guidelines and home health sequencing conventions where credentialed
• Escalate coding or OASIS conflicts to Mosai clinical operations
• Produce written, compliant, non-leading recommendations with supporting documentation, applicable guidance, and clinical rationale
• Enter recommendations through client-defined channels, meet turnaround commitments, and track recommendations to closure
• Work across multiple client agencies and EMR platforms
• Complete client-required onboarding and access provisioning
• Protect PHI and never enter, alter, or fabricate clinical documentation
• Maintain required review accuracy, participate in calibration exercises, and report false positives, missed findings, and outdated guidance references
• Route questions, disagreements, and escalations through Mosai clinical operations and client services

Oasis Reviewer

• Review clinical test results from molecular genetic testing laboratories for accuracy and translate results into LIMS
• Review and analyze raw data files in appropriate software and resolve routine issues
• Verify the correct specimen and tests for patients by reviewing test requisition forms
• Work within laboratory information systems to review and correct patient demographics
• Understand and follow current applicable standard operating procedures
• Ensure compliance with regulatory agency requirements through documentation, audits, corrective action, and GLP practices
• Comply with company and department policies and procedures while handling PHI in paper and electronic forms
• Complete HIPAA/PHI privacy, general policies and procedures compliance, and security training within the first 30 days of hire
• Perform other duties as assigned

Data Reviewer

• Access and review medical record documentation, coding and abstracting accuracy according to quality review policies and facility guidelines
• Utilize ICD-10-CM/PCS and CPT coding classification systems
• Review patient records via facility EMR, scanning technology or another established method
• Enter all reviews daily into Guidehouse proprietary quality review tracking and trending software
• Respond to coder rebuttals within the timelines defined in quality review policies and procedures
• Perform related job duties as assigned
• Report directly to the Internal Quality Control Director

IP Quality Reviewer

• Review and analyze complex medical, psychological, developmental, and functional information for children applying for or participating in Wisconsin’s Katie Beckett Medicaid program
• Develop disability determination recommendations using medical evidence, functional limitations, Social Security Act requirements and disability criteria, policies, regulations, procedures, and quality standards
• Evaluate medical terminology, disease processes, diagnostic testing, treatment practices, physical and mental impairments, and other relevant evidence
• Identify when additional medical information is necessary to complete a review
• Prepare electronic case documentation, written review requests, case summaries, determination records, and required notifications
• Maintain confidentiality and comply with applicable regulations and program requirements
• Independently manage an assigned disability caseload
• Collaborate with reviewers, clinical consultants, supervisors, and operational partners to research discrepancies, resolve complex cases, and reach logical and objective conclusions
• Travel quarterly to Madison, Wisconsin for meetings or other business needs

Disability Reviewer

• Conduct comprehensive reviews of clinical cases
• Apply specialized neuroradiology expertise to provide objective, evidence-based medical advisory opinions
• Review medical records, radiology reports, and relevant neuroimaging documentation
• Prepare clear and concise clinical summaries
• Respond to client questions regarding neuroradiologic findings, diagnoses, imaging appropriateness, and medical care
• Perform advisory medical record reviews only, without peer-to-peer discussions, calls, or direct patient care

Reviewer jobs in United States