MedReview Inc.

Reviewer

• Analyze and review inpatient claims following the Official Coding and Reporting Guidelines to validate the reported ICD-10-CM/PCS codes to ensure proper DRG assignment for accurate billing.
• Demonstrates the ability to perform a comprehensive initial review as outlined in the standard operating procedures and departmental guides.
• Collaborates with physician reviewers, as needed.
• Ability to prioritize and organize workload and complete tasks independently.
• Required attendance of all departmental team meetings and/or training.
• Work on other duties or tasks, as necessary.
• Report productivity daily utilizing department productivity report.
• Meet/exceed daily productivity expectations.
• Maintains 95% accuracy in claim reviews.
• Must be available to work a 7.5-hour workday during Eastern Standard Time (EST) business hours.
• Comply with organization policy and procedures.

DRG Reviewer

Pricing Analyst

• Responsible for reviewing data in the review application and client claim processing system, and comparing with corresponding UB, medical record or other documentation.
• Responsible for reviewing all necessary documentation as necessary to determine appropriate reimbursement for a claim.
• Responsible for reviewing adjudication software system’s claim and line items for determination of how to price a claim / line item.
• Possess ability to work at a computer for extended periods.
• Other duties as assigned.

Pricing Resolution Specialist

General

• Perform DRG Clinical Validation reviews to ensure diagnoses are accurate, supported, and compliant
• Evaluate medical records, diagnostic findings, and treatment plans using evidence-based guidelines
• Produce clear, concise clinical summaries and determinations within established turnaround times
• Identify opportunities for improved documentation, coding accuracy, and cost containment
• Conduct readmission and level of care reviews, including outlier and appeal cases
• Collaborate with internal teams and, when needed, engage with providers to support clinical findings
• Contribute to quality assurance initiatives and ongoing program development.

Physician Reviewer

Product Specialist

• Serve as the primary SNF domain expert for the product development team by translating regulatory and clinical requirements into audit rules, workflows and operational processes.
• Validate and refine SNF audit methodology, including medical necessity criteria, documentation standards and coding requirements.
• Define MVP scope, roadmap enhancements and implementation readiness.
• Apply deep knowledge of CMS SNF regulations, PDPM, MDS/RAI, therapy documentation and state Medicaid policies.
• Monitor regulatory updates and recommend product adjustments as needed.
• Define and validate claim selection logic, risk indicators and scoring models.
• Develop and validate end-to-end workflows, including intake, clinical review, provider outreach and appeals.
• Define SLA expectations for turnaround times, provider response windows and internal review cycles.
• Support training for clinical reviewers, auditors and provider engagement teams.
• Define reporting needs for audit outcomes, savings, provider trends and operational KPIs.
• Partner with analytics to ensure dashboards and reporting tools are accurate and actionable.
• Identify opportunities for continuous improvement based on audit results.
• Serve as SME during product implementation, ensuring all components are ready for deployment.

Payment Integrity Product Development Specialist

• Assist Appeals leadership with daily administrative work within the department.
• Perform research, investigation, and analysis of appeals, grievances, and other types of complaints filed by providers and clients to administer timely resolution.
• Perform responsibilities for all aspects of nonclinical appeals and inquiries.
• Prepare and disseminate case file for External Reviews and/or State Fair Hearing.
• Manage and monitor all appeals from Non-Participating providers.
• Independently prepare well written, customized responses to all provider inquiries/complaints that appropriately and completely address the complainant’s issues and are structurally accurate.
• Ensure timely review, research, and resolution of appeals, grievances, and complaints within guidelines.
• Consult with managers on problem cases and interface with clinical supervisors, account managers, and other personnel in resolving health plan requests or provider inquiries.
• Log and track grievances, appeals, and other types of complaints as needed.
• Review and determine outcome of appeal/grievance, either independently or in conjunction with clinical appeal staff.
• Consult with subject matter experts and resources available within organization to assist in appeal and complaint resolution.
• Make critical decisions regarding research and investigation to appropriately resolve all inquiries.
• Serve as a liaison to Appeal Coordinator providing guidance and expertise to ensure timely resolution of cases.

DRG Reviewer

Pricing Resolution Specialist

Physician Reviewer

Payment Integrity Product Development Specialist

Appeals Specialist II