Medical Reviewer, Medicare
Simsy Ventures
full-time
Posted on:
Location Type: Remote
Location: United States
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About the role
- 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
Requirements
- Active, unrestricted RN license in the U.S. and in the state of hire OR
- Active compact multistate RN license (as defined by the Nurse Licensure Compact)
- Associate Degree in Nursing OR
- Graduate of an accredited School of Nursing
- Two years of clinical experience plus at least two years in one of the following:
- Inpatient/Outpatient settings (i.e. medical-surgical, rehabilitation, SNF, etc..)
- Utilization/Medical Review
- Quality Assurance
- Strong clinical background in managed care and/or inpatient/outpatient settings
- Ability to interpret and apply medical review criteria and clinical guidelines
- Proficiency in Microsoft Office and word processing software
- Strong analytical, organizational, and decision-making skills
- Ability to work independently while managing priorities effectively
- Excellent customer service, communication, and critical thinking skills
- Ability to handle confidential information with discretion
Benefits
- High-speed internet (non-satellite) and a private, lockable home office
- All necessary equipment to perform your job effectively, including but not limited to a desktop computer, dual monitors, a headset, an ethernet cable, and additional accessories as needed.
Applicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills & Tools
clinical criteriamedical reviewpayment determinationsmedical necessitycoverage reimbursementcoding requirementsutilization reviewquality assuranceanalytical skillsdecision-making
Soft Skills
organizational skillsindependent workcustomer servicecommunication skillscritical thinkingability to manage prioritiesdiscretion
Certifications
RN licensecompact multistate RN licenseAssociate Degree in Nursingaccredited School of Nursing graduate