Senior Clinical Reviewer

The range for this role is $31.97 per hour to $43.51 per hour

Actual base pay will be determined based on a successful candidate's work location, skills/abilities, experience, and education.

Interested applicants must be willing and able to work onsite minimum 4 times per week in either our Melbourne, FL or Orlando, FL office.

At Christian Care Ministry we believe that Christians can, and should, share in one another’s burdens. Through the use of Medi-Share®, a healthcare sharing ministry for Christians, we cultivate that belief. To that end, our Mission Statement is as follows:
Connecting people to a Christ-centered community wellness experience based on faith, prayer, and personal responsibility.

Everyone at Christian Care Ministry is in agreement with our Statement of Faith, which outlines our core beliefs. Although we aren’t perfect people, we are serving our perfect God and our Members to the best of our ability.

The Senior Clinical Reviewer works to summarize and correlate concise, accurate information on medical reviews to determine eligibility of medical bills per the program guidelines. In this role, 70% of the time is spent performing pre-service and post-service medical reviews and/or reviews for high dollar, complex medical cases and collaborating with other departments to optimize cost savings. This position leverages AI-enabled clinical review tools and electronically ingested data (278 transactions) to enhance the accuracy, efficiency, and consistency of medical reviews.

The Senior Clinical Reviewer will be expected to make decisions regarding timing and omission of medical reviews in deference to other department processes based on the dollar amount of the bill and the Ministry’s cost strategy.

• Organize and review medical records, lab results, radiology, and pathology reports for conditions ineligible for sharing (CIF’s)
• Determine eligibility of members’ medical bills and/or upcoming procedures/treatments according to the program guidelines
• Perform pre-service and post-service medical reviews utilizing AI-enabled clinical review tools to make evidence-based, consistent, and efficient determinations of sharing eligibility
• Review and interpret pre-service eligibility data (via 278 EDI transactions) to support streamlined medical review workflows
• Integrate structured electronic data with clinical documentation to support accurate and timely eligibility determinations
• Collaborate with other departments to maximize cost savings for individual cases and optimal outcomes for the members
• Appropriately apply the program guidelines to the individual cases reviewed
• Work autonomously to prioritize and manage workload
• Document effectively in appropriate systems, including outputs supported by AI tools and electronic data ingestion processes
• Comply with all organizational HIPAA requirements and ensure proper handling of electronic transaction data
• Support process improvements related to automation, using AI tools and electronic data ingestion workflows
• Contribute to the exercise and expression of the Ministry’s Christian beliefs
• All other duties as assigned

• Understanding of medical bill processing and provider bill negotiation
• Knowledge and practical application of AI-assisted medical review tools and clinical decision support technologies
• Ability to understand Availity 278 transactions and electronic pre-service eligibility workflows
• Ability to interpret structured electronic data and integrate it with clinical documentation during the medical review process
• Ability to multitask in multiple operating systems
• Ability to work for extended periods of time on the computer
• Proficiency in interpreting medical records and writing detailed reports and conclusions
• Strategic understanding of negotiations, third party processes, bill validation, and care management to determine when to utilize/defer to these processes for active review cases
• Ability to be objective and impartial and conclude a case
• Ability to communicate effectively with both internal and external customers
• Interpersonal skills and ability to work as a member of a…