Simsy Ventures

Medical Reviewer

• Performs medical claim reviews for one or more of the following: claims for medically complex services, services that require preauthorization/predetermination, requests for appeal or reconsideration, referrals for potential fraud and/or abuse, and correct coding for claims/operations.
• Makes reasonable charge payment determinations based on clinical/medical information and established criteria/protocol sets or clinical guidelines.
• Determines medical necessity and appropriateness and/or reasonableness and necessity for coverage and reimbursement.
• Documents medical rationale to justify payment or denial of services and/or supplies.
• Educates internal/external staff regarding medical reviews, medical terminology, coverage determinations, coding procedures, etc. in accordance with contractor guidelines.
• Participates in quality control activities in support of the corporate and team-based objectives.
• Provides guidance, direction, and input as needed to LPN team members.
• Provides education to non-medical staff through discussions, team meetings, classroom participation and feedback.
• Assists with special projects and specialty duties/responsibilities as assigned by Management.

Medical Claims Reviewer – Home Health

Analyst

• Support the full lifecycle of medical provider enrollment, helping ensure accurate provider data and regulatory compliance.
• Review and validate medical provider enrollment applications (initial, re-enrollment, reactivation, or updates)
• Verify provider data via internal databases and external agencies; set up/test EFT accounts
• Enter and update provider information in enrollment databases and directories
• Communicate with providers, agencies, and internal departments to resolve discrepancies
• Supply application materials and process guidance to potential enrollees
• Assist with special projects, process improvements, provider education, and system testing

Provider Enrollment Analyst, CMS 855 Required

Program Manager

• Serve as the primary liaison between the organization and the WTC Health Program, including communication with Program Management, Contracting Officer (CO), and Contracting Officer Representative (COR)
• Provide end-to-end oversight of contract operations, ensuring all deliverables meet quality, timeliness, and compliance standards
• Lead execution of a comprehensive cost avoidance, COB, and recovery program across pre- and post-payment processes
• Ensure accurate and timely submission of reports, deliverables, and ad hoc requests
• Oversee implementation and adherence to a robust quality assurance program
• Manage cross-functional teams supporting:
• Insurance identification and verification
• Coordination of benefits (COB)
• Claims recovery (OHI & Workers’ Compensation)
• Payment integrity and fraud, waste, and abuse (FWA) efforts
• Maintain effective communication channels with internal staff and external stakeholders, including government entities and program partners
• Drive performance monitoring, operational improvements, and cost containment strategies
• Ensure compliance with federal regulations, HIPAA requirements, and contractual obligations
• Foster and maintain strong business relationships with all program stakeholders

Medical Claims Reviewer – Home Health

Provider Enrollment Analyst, CMS 855 Required

Program Director – WTC Health Program, COB & Recovery Program