Medical Reviewer II
Job Description:
- Performs medical claim reviews for medically complex services, preauthorization/predetermination requests, appeals or reconsiderations, potential fraud and/or abuse referrals, and correct coding for claims/operations
- Makes reasonable charge payment determinations using clinical/medical information and established criteria, protocol sets, or clinical guidelines
- Determines medical necessity, appropriateness, and reasonableness for coverage and reimbursement
- Monitors process timeliness in accordance with contractor standards
- Documents medical rationale supporting payment or denial of services and/or supplies
- Educates internal and external staff regarding medical reviews, medical terminology, coverage determinations, and coding procedures
- Participates in quality control activities supporting corporate and team-based objectives
- Provides guidance, direction, and input to LPN team members
- Educates non-medical staff through discussions, team meetings, classroom participation, and feedback
- Assists with special projects and specialty duties assigned by management
Requirements:
- Associate's in a job-related field
- Graduate of Accredited School of Nursing
- 2 years clinical experience
- Working knowledge of word processing software
- Ability to work independently, prioritize effectively, and make sound decisions
- Good judgment skills
- Demonstrated customer service and organizational skills
- Demonstrated oral and written communication skills
- Analytical or critical thinking skills
- Ability to handle confidential or sensitive information with discretion
- Microsoft Office
- Active RN licensure in state hired, OR, active compact multistate RN license as defined by the Nurse Licensure Compact (NLC)
- U.S. Citizenship required to obtain the required security clearance
- Ability to work an 8-hour shift during normal business hours, Monday-Friday, with occasional overtime as needed
Benefits:
- Subsidized health plans, dental and vision coverage
- 401k retirement savings plan with company match
- Life Insurance
- Paid Time Off (PTO)
- On-site cafeterias and fitness centers in major locations
- Education Assistance
- Service Recognition
- National discounts to movies, theaters, zoos, theme parks and more
