Medical Reviewer

• Perform medical claim reviews for claims for medically complex services, services that require preauthorization/predetermination, requests for appeal or reconsideration, referrals for potential fraud and/or abuse, correct coding for claims/operations.
• Make reasonable charge payment determinations based on clinical/medical information and established criteria/protocol sets or clinical guidelines.
• Determine medical necessity and appropriateness and/or reasonableness and necessity for coverage and reimbursement.
• Monitors process’s timeliness in accordance with contractor standards.
• Document medical rationale to justify payment or denial of services and/or supplies.
• Educate internal/external staff regarding medical reviews, medical terminology, coverage determinations, coding procedures, etc. in accordance with contractor guidelines.
• Participate in quality control activities in support of the corporate and team-based objectives.
• Provide 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.

RN Medical Reviewer III

• Perform medical claim reviews for claims for medically complex services, services that require preauthorization/predetermination, requests for appeal or reconsideration, referrals for potential fraud and/or abuse, correct coding for claims/operations.
• Make reasonable charge payment determinations based on clinical/medical information and established criteria/protocol sets or clinical guidelines.
• Determine medical necessity and appropriateness and/or reasonableness and necessity for coverage and reimbursement.
• Monitor process’s timeliness in accordance with contractor standards.
• Document medical rationale to justify payment or denial of services and/or supplies.
• Educate internal/external staff regarding medical reviews, medical terminology, coverage determinations, coding procedures, etc. in accordance with contractor guidelines.
• Participate in quality control activities in support of the corporate and team-based objectives.
• Provide guidance, direction, and input as needed to LPN team members.
• Provide education to non-medical staff through discussions, team meetings, classroom participation, and feedback.
• Assist with special projects and specialty duties/responsibilities as assigned by management.

• Performs medical reviews using clinical/medical information provided by physicians/providers and established criteria/protocol sets or clinical guidelines
• Documents decisions using indicated protocol sets or clinical guidelines
• Provides support and review of medical claims and utilization practices
• Participate in quality control activities in support of the corporate and team-based objectives
• Perform 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, correct coding for claims/operations
• Make reasonable charge payment determinations based on clinical/medical information and established criteria/protocol sets or clinical guidelines
• Document medical rationale to justify payment or denial of services and/or supplies

Medical Reviewer III

• Perform 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, correct coding for claims/operations
• Make reasonable charge payment determinations based on clinical/medical information and established criteria/protocol sets or clinical guidelines
• Determine medical necessity and appropriateness and/or reasonableness and necessity for coverage and reimbursement
• Monitor process’s timeliness in accordance with contractor standards
• Document medical rationale to justify payment or denial of services and/or supplies
• Educate internal/external staff regarding medical reviews, medical terminology, coverage determinations, coding procedures, etc. in accordance with contractor guidelines
• Participate in quality control activities in support of corporate and team-based objectives
• Provide guidance, direction, and input as needed to LPN team members
• Provide education to non-medical staff through discussions, team meetings, classroom participation, and feedback
• Assist with special projects and specialty duties/responsibilities as assigned by management

• Assess the medical necessity and quality of healthcare services through prospective, concurrent, and retrospective utilization management reviews
• Apply Alabama Medicaid program criteria and guidelines to determine medical necessity
• Complete reviews within timelines established by all applicable state and federal requirements
• Consult and forward cases for which a medical necessity determination cannot be rendered
• Identify customer needs and expectations and respond to them in a timely and effective manner
• Attend Medicaid meetings, fair hearings, and legislative committee meetings as required

Clinical Reviewer, RN

• Perform Clinical Review work and QIDP reviews
• Apply Alabama Medicaid program criteria and guidelines
• Complete reviews within timelines established by state and federal requirements
• Consult with Physician Advisor/Consulting Physician for complex cases
• Work with administrative support
• Identify customer needs and respond timely
• Attend Medicaid meetings, fair hearings, and legislative committee sessions as requested

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