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
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