About the position
The Medical Reviewer I position involves performing medical reviews and utilization management for professional, inpatient, or outpatient services. The role requires documenting decisions based on established criteria and providing support for medical claims and utilization practices. The position is remote and is expected to last for a duration of 3 months, with the possibility of extensions.
Responsibilities
- Perform medical claim reviews and make reasonable charge payment determinations. ,
- Monitor process timeliness in accordance with contractor standards. ,
- Perform authorization processes, ensuring coverage for appropriate medical services within benefit and medical necessity guidelines. ,
- Utilize allocated resources to back up review determinations. ,
- Review interdepartmental requests and medical information in a timely manner to complete the utilization process. ,
- Conduct high dollar forecasting research and formulate overall patient health summaries with future health prognosis and projected medical costs. ,
- Perform screenings/assessments and determine risk via telephone. ,
- Review and determine eligibility, level of benefits, and medical necessity of services. ,
- Provide education to members and their families/caregivers. ,
- Review first level appeals and ensure thorough documentation of each determination and basis for each. ,
- Conduct necessary research to make thorough and accurate determinations. ,
- Educate internal/external staff regarding medical reviews, medical terminology, coverage determinations, and coding procedures. ,
- Respond accurately and timely with appropriate documentation to members and providers on all rendered determinations. ,
- Participate in quality control activities in support of corporate and team-based objectives.
Requirements
- Bachelor's degree in Social Work or Graduate of an Accredited School of Licensed Practical Nursing or Licensed Vocational Nursing. ,
- 2 years of clinical experience. ,
- Active, unrestricted LPN/LVN licensure from the United States and in the state of hire, or active compact multistate unrestricted LPN license as defined by the Nurse Licensure Compact (NLC), or active, unrestricted LBSW licensure from the United States and in the state of hire.
Nice-to-haves
- Associate Degree in Nursing or Graduate of an Accredited School of Nursing. ,
- Active, unrestricted RN licensure from the United States and in the state of hire, or active compact multistate unrestricted RN license as defined by the Nurse Licensure Compact (NLC).
Benefits
- ACA compliant health benefits ,
- Dental insurance ,
- Vision insurance ,
- Accident insurance ,
- Critical illness insurance ,
- Voluntary life insurance ,
- Hospital indemnity insurance ,
- Commuter benefits ,
- 401K plan with matching ,
- Referral bonus program ,
- Unpaid leave ,
- Paid sick leave when required by law