FHAS, LLC

Reviewer

• Provide timely review and determination of medical claims, including prior authorization, appeals, and/or any other type of medical claims;
• Analyze medical records related to the case file;
• Review and interpret Local Coverage Determination (LCD), National Coverage Determination (NCD) policies, and other federal regulations;
• Apply appropriate regulatory citations, including health plan policies, NCD/LCDs, and/or other regulations to each claim as it relates to the item or issue;
• Formulate a narrative decision citing relevant regulatory back-up documentation contained within the medical record;
• Adjudicate claim based on the regulations and documentation contained within the medical record;
• Attend FHAS and/or client Lunch & Learn sessions and/or general training sessions on site as needed.
• Complete IRR surveys in a timely fashion as required by the prime contractor Maintain a 97% or higher quality score work experience requirements

Nurse Reviewer, RN