Medical Reviewer I
Palmetto GBA
full-time
Posted on:
Location Type: Remote
Location: South Carolina • United States
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About the role
- Evaluate the medical records to determine medical necessity and perform utilization management of professional, inpatient, 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
- Perform medical claim reviews and makes a reasonable charge payment determination
- 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
- 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 with contractor guidelines
Requirements
- Bachelor's degree - Social Work, OR, Graduate of an Accredited School of Licensed Practical Nursing or Licensed Vocational Nursing
- 2 years clinical experience
- 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
- 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
Benefits
- Subsidized health plans
- Dental and vision coverage
- 401k retirement savings plan with company match
- Life Insurance
- Paid Time Off (PTO)
- On-site cafeterias and fitness centers in major locations
- Education Assistance
- Service Recognition
- National discounts to movies, theaters, zoos, theme parks and more
Applicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills & Tools
medical record evaluationutilization managementmedical claims reviewauthorization processcoding proceduresclinical guidelinesanalytical skillscritical thinking
Soft Skills
good judgmentcustomer serviceorganizational skillsdiscretioncommunication skills
Certifications
LPN licenseLVN licenseLBSW licensure