Medical Reviewer

• Perform accurate and timely medical review of claims suspended for medical necessity
• Initiate and/or respond to correspondence from providers or members concerning medical determinations

Medical Reviewer II responsible for reviewing medical claims for HCSC

Medical Reviewer II

Medical Reviewer II at HCSC responsible for performing medical review of claims and responding to correspondence. Requires RN license and clinical experience.

• Assess the medical necessity and quality of healthcare services through utilization management reviews
• Conduct prospective, concurrent, and retrospective utilization management reviews
• Apply clinical review criteria, organizational policies, guidelines, and screening tools (InterQual)
• Consult with physician/practitioner consultants when services do not meet medical necessity criteria
• Collaborate with internal teams and refer cases for additional review or escalation as appropriate
• Refer cases to management when required
• Provide clinical and utilization review subject matter expertise
• Respond to provider, customer, and stakeholder questions regarding determinations and processes
• Conduct outreach to providers, case managers, consultants, and community support coordinators to obtain additional clinical information
• Maintain accurate documentation and comply with all regulatory and contract standards

Clinical Reviewer assessing the medical necessity and quality of healthcare services

Clinical Reviewer

Clinical Reviewer in a nonprofit improving healthcare quality through utilization management reviews. Remote, full-time role for RN with patient care experience in New Mexico.

Medical Reviewer jobs in New Mexico

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Medical Reviewer II

Clinical Reviewer