Medical Reviewer

Job Responsibilities

• Perform medical reviews using established criteria sets and/or performs utilization management of professional, inpatient or outpatient, facility benefits or services, and appeals.
• Document decisions using indicated protocol sets or clinical guidelines.
• Provide support and review of medical claims and utilization practices.
• Monitor process's timeliness in accordance with contractor standards.
• Perform authorization process, ensuring coverage for appropriate medical services within benefit and medical necessity guidelines.
• Utilize allocated resources to back up review determination.
• Review interdepartmental requests and medical information in a timely/effective manner to complete utilization process.
• Conduct/perform 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/determine eligibility, level of benefits, and medical necessity of services and/or reasonableness and necessity of services.
• Provide education to members and their families/caregivers.
• Review first level appeal and ensure utilization or claim review provides thorough documentation of each determination and basis for each.
• Conduct research necessary to make thorough/accurate basis for each determination made.
• Educate internal/external staff regarding medical reviews, medical terminology, coverage determinations, coding procedures, etc. in accordance to contractor guidelines.
• Respond accurately and timely with appropriate documentation to members and providers on all rendered determinations.
• Participate in quality control activities in support of the corporate and team-based objectives.

• Required
  
  Education:
  
  Bachelor's degree - Social Work, OR, Graduate of an Accredited School of Licensed Practical Nursing or Licensed Vocational Nursing.
• Required Experience:
  
  2 years clinical experience.
• Required
  
  Skills and Abilities:
  
  Working knowledge of word processing software.
• Good judgment skills.
• Demonstrated customer service and organizational skills.
• Demonstrated proficiency in spelling, punctuation, and grammar skills.
• Analytical or critical thinking skills.
• Ability to handle confidential or sensitive information with discretion.
• Ability to remain in a stationary position and operate a computer.
• Required Software and Tools:
  Microsoft Office.
• Required Licenses and Certificates:
  Active, unrestricted LPN/LVN licensure from the United States and in the state of hired, OR, active compact multistate unrestricted LPN license as defined by the Nurse Licensure Compact (NLC), OR, active, unrestricted LBSW (Licensed Bachelor of Social Work) licensure from the United States and in the state of hire.

• LPN licensure
• LVN licensure
• LBSW licensure

• Microsoft Office
• word processing software