Medical Reviewer

• Conducts medical record audits to determine medical necessity and/or appropriateness of medical treatment per SOW and CMS directives
• Conducts in-depth claims analysis utilizing knowledge of medical terminology, ICD-9-CM, ICD-10-CM, CPT-4, APR-DRG, and HCPCS Level II
• Utilizes payer guidelines for coverage determinations and clinical review judgment
• Provides electronic documentation of findings and conclusions with determinations of claims payment appropriateness
• Reviews the Master Policy List and MR questionnaire for each State prior to claim review
• Ensures MR department compliance with quality management system and ISO requirements
• Utilizes electronic documentation and spreadsheets to track productivity and claim determination trends
• Participates in QA and IRR monitoring as requested
• Complies with departmental policies and QA/productivity benchmarks
• Attends departmental or required education and training programs
• Effectively communicates with management and colleagues
• Performs other projects or duties as assigned by Senior Medical Review Specialist or Medical Review Manager

Medical Reviewer III, Medicaid

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Medical Reviewer II

RN – Medical Claims Reviewer

QHCP Clinical Reviewer – NP, PA, CNM