Medical Reviewer (Remote)

Key Responsibilities

• Handle a variety of claim types, including Radiology, Ambulance, Physical Therapy, and Surgical.
• Use clinical information from physicians and providers, Medicare guidelines, and established criteria to determine medical necessity, coverage, and payment, and document each decision.
• Review medical claims, which may include medically complex services, preauthorization or predetermination requests, appeals and reconsiderations, potential fraud and abuse referrals, and correct coding reviews.
• Document the medical rationale supporting payment or denial of services and supplies.
• Educate internal and external staff, including non-medical staff, on medical review, terminology, coverage determinations, and coding.
• Provide guidance and direction to LPN team members as needed.
• Take part in quality control activities that support team and corporate objectives.
• Assist with special projects and specialty assignments as directed by management.

Minimum Requirements

• License: Active, unrestricted RN license in the U.S. and in the state of hire, or an active, unrestricted multistate RN license under the Nurse Licensure Compact.
• Education: Associate's degree in nursing or graduate of an accredited school of nursing.
• Experience: 2 years of clinical experience plus 2 years in utilization or medical review, quality assurance, or home health.
• Clinical Background: Home health, rehabilitation, and/or broad medical-surgical experience.
• Skills: Working knowledge of criteria and protocol sets, managed care, and health care delivery systems; proficiency in Microsoft Office; strong written and verbal communication; sound judgment and critical thinking; ability to work independently, prioritize, and handle confidential information.
• Clearance: Must be able to pass the CMS background investigation and complete fingerprinting and EUA/system access clearance in a timely manner.

Preferred Qualifications

• Bachelor of Science in Nursing (BSN)
• 5 years of clinical experience plus 3 years in utilization or medical review, quality assurance, or home health
• Medicare Part B claims review experience and knowledge of Medicare regulations and policies
• Experience with spreadsheet and database software