Reviewer I, Medical
Performs medical reviews using established criteria sets and/or performs utilization management of professional, inpatient or outpatient, facility benefits or services, and appealsDocuments decisions using indicated protocol sets or clinical guidelinesProvides support and review of medical claims and utilization practices.
80% May provide any of the following in support of medical claims review and utilization review practices:
Performs medical claim reviews and makes a reasonable charge payment determinationMonitors process's timeliness in accordance with contractor standardsPerforms authorization process, ensuring coverage for appropriate medical services within benefit and medical necessity guidelinesUtilizes allocated resources to back up review determinationReviews interdepartmental requests and medical information in a timely/effective manner in order to complete utilization processMay conduct/perform high dollar forecasting research and formulate overall patient health summaries with future health prognosis and projected medical costsPerforms screenings/assessments and determines risk via telephoneReviews/determines eligibility, level of benefits, and medical necessity of services and/or reasonableness and necessity of servicesProvides education to members and their families/caregiversReviews first level appeal and ensures utilization or claim review provides thorough documentation of each determination and basis for eachConducts research necessary to make thorough/accurate basis for each determination made.
10% Educates internal/external staff regarding medical reviews, medical terminology, coverage determinations, coding procedures, etcin accordance with contractor guidelinesResponds accurately and timely with appropriate documentation to members and providers on all rendered determinations10% Participates in quality control activities in support of the corporate and team-based objectivesParticipates in all required training.
Required Skills and Abilities:
Working knowledge of word processing softwareGood judgment skillsDemonstrated customer service and organizational skillsDemonstrated proficiency in spelling, punctuation, and grammar skillsAnalytical or critical thinking skillsAbility to handle confidential or sensitive information with discretionAbility to remain in a stationary position and operate a computerRequired Software and Tools:
Microsoft OfficePreferred Skills and Abilities:
Working knowledge of spreadsheet and database softwareDemonstrated oral and written communication skillsAbility to persuade, negotiate, or influence othersPreferred Software and Others Tools:
Knowledge of Microsoft Excel, Access, or other spreadsheet/database softwareWork Environment:
Typical office environment some travel between office buildings.
Recommended Skills Analytical Assessments Claim Processing Clinical Works Communication Coordinating Apply to this job.
Think you're the perfect candidate? Apply on company site $('.
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on('click', function (event) window.
ExternalApply = window.
open('/interstitial?jobdid=j3q78s6j69r756x0msv', 'ExternalApply-j3q78s6j69r756x0msv'); ); Estimated Salary: $20 to $28 per hour based on qualifications.
80% May provide any of the following in support of medical claims review and utilization review practices:
Performs medical claim reviews and makes a reasonable charge payment determinationMonitors process's timeliness in accordance with contractor standardsPerforms authorization process, ensuring coverage for appropriate medical services within benefit and medical necessity guidelinesUtilizes allocated resources to back up review determinationReviews interdepartmental requests and medical information in a timely/effective manner in order to complete utilization processMay conduct/perform high dollar forecasting research and formulate overall patient health summaries with future health prognosis and projected medical costsPerforms screenings/assessments and determines risk via telephoneReviews/determines eligibility, level of benefits, and medical necessity of services and/or reasonableness and necessity of servicesProvides education to members and their families/caregiversReviews first level appeal and ensures utilization or claim review provides thorough documentation of each determination and basis for eachConducts research necessary to make thorough/accurate basis for each determination made.
10% Educates internal/external staff regarding medical reviews, medical terminology, coverage determinations, coding procedures, etcin accordance with contractor guidelinesResponds accurately and timely with appropriate documentation to members and providers on all rendered determinations10% Participates in quality control activities in support of the corporate and team-based objectivesParticipates in all required training.
Required Skills and Abilities:
Working knowledge of word processing softwareGood judgment skillsDemonstrated customer service and organizational skillsDemonstrated proficiency in spelling, punctuation, and grammar skillsAnalytical or critical thinking skillsAbility to handle confidential or sensitive information with discretionAbility to remain in a stationary position and operate a computerRequired Software and Tools:
Microsoft OfficePreferred Skills and Abilities:
Working knowledge of spreadsheet and database softwareDemonstrated oral and written communication skillsAbility to persuade, negotiate, or influence othersPreferred Software and Others Tools:
Knowledge of Microsoft Excel, Access, or other spreadsheet/database softwareWork Environment:
Typical office environment some travel between office buildings.
Recommended Skills Analytical Assessments Claim Processing Clinical Works Communication Coordinating Apply to this job.
Think you're the perfect candidate? Apply on company site $('.
external-apply-email-saved').
on('click', function (event) window.
ExternalApply = window.
open('/interstitial?jobdid=j3q78s6j69r756x0msv', 'ExternalApply-j3q78s6j69r756x0msv'); ); Estimated Salary: $20 to $28 per hour based on qualifications.
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