Simsy Ventures

Medical Reviewer

• Assist Medical Review Management with monitoring the medical review process
• Conduct medical record reviews for complex services
• Evaluate compliance with Medicare coverage, coding, and billing rules
• Contribute to medical review and proposal deliverables
• Participate in quality assurance activities to ensure consistency and accuracy

Senior Medical Reviewer

Medical Billing and Coding

• Support medical review activities through complex coding validations
• Perform complex coding validations for accuracy reviews, disputes/disagreements, special studies, and review topic proposals
• Contribute documentation and analysis for coding validation deliverables
• Participate in quality assurance activities to ensure accuracy of coding determinations

Certified Coder

• Conducting pre- and post-payment medical reviews to ensure compliance with established clinical criteria and guidelines
• Review medically complex claims, pre-authorization requests, appeals, and fraud/abuse referrals
• Assess payment determinations using clinical information and established guidelines
• Evaluate medical necessity, appropriateness, and reasonableness for coverage and reimbursement
• Provide clear, well-documented rationales for service approvals or denials
• Educate internal and external teams on medical review processes, coverage determinations, and coding requirements
• Support quality control activities to meet corporate and team objectives
• Assist with special projects and additional responsibilities as assigned

Senior Medical Reviewer

Certified Coder

Medical Reviewer, Medicare