Medical Reviewer

• Perform medical reviews using established criteria sets and/or performs utilization management of professional, inpatient or outpatient, facility benefits or services, and appeals.
• Document decisions using indicated protocol sets or clinical guidelines.
• Provide support and review of medical claims and utilization practices.
• Monitor process's timeliness in accordance with contractor standards.
• Perform authorization process, ensuring coverage for appropriate medical services within benefit and medical necessity guidelines.
• Utilize allocated resources to back up review determination.
• Review interdepartmental requests and medical information in a timely/effective manner to complete utilization process.
• Conduct/perform high dollar forecasting research and formulate overall patient health summaries with future health prognosis and projected medical costs.
• Perform screenings/assessments and determine risk via telephone.
• Review/determine eligibility, level of benefits, and medical necessity of services and/or reasonableness and necessity of services.
• Provide education to members and their families/caregivers.
• Review first level appeal and ensure utilization or claim review provides thorough documentation of each determination and basis for each.
• Conduct research necessary to make thorough/accurate basis for each determination made.
• Educate internal/external staff regarding medical reviews, medical terminology, coverage determinations, coding procedures, etc. in accordance with contractor guidelines.
• Respond accurately and timely with appropriate documentation to members and providers on all rendered determinations.
• Participate in quality control activities in support of the corporate and team-based objectives.

Medical Reviewer I

• 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

• Performs medical review 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.
• 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.
• Monitors process’s timeliness in accordance with contractor standards.
• 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.

RN Medical Reviewer II

• 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, 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.
• Monitors process’s timeliness in accordance with contractor standards.
• 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.

• Conduct prepayment and post-payment audits of DRG coding and clinical documentation
• Validate the appropriateness of billed ICD-10-CM and ICD-10 PCS codes and MS-DRGs
• Generate Decision Action Notices that provide clear rationales referencing clinical evidence
• Participate in both informal and formal appeal processes, defending decisions
• Propose new fraud prevention edits for the automated claims and billing system

Complex Claims Clinical Reviewer

Medical Reviewer II

• 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
• 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
• Monitors process’s timeliness in accordance with contractor standards
• 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

• Evaluate the medical records to determine medical necessity and perform utilization management of professional, inpatient, outpatient facility benefits or services and appeals
• Document decisions using indicated protocol sets, or clinical guidelines
• Provide support and review of medical claims and utilization practices
• Perform medical claim reviews and makes a reasonable charge payment determination
• Monitor process's timeliness in accordance with contractor standards
• Perform authorization process, ensuring coverage for appropriate medical services within benefit and medical necessity guidelines
• Utilize allocated resources to back up review determination
• Conduct research necessary to make thorough/accurate basis for each determination made
• Educate internal/external staff regarding medical reviews, medical terminology, coverage determinations, coding procedures, etc. in accordance with contractor guidelines

• Evaluate medical records to determine medical necessity
• Perform utilization management of professional, inpatient, outpatient facility benefits or services and appeals
• Document decisions using indicated protocol sets or clinical guidelines
• Provide support and review of medical claims and utilization practices
• Perform authorization process, ensuring coverage for appropriate medical services within benefit and medical necessity guidelines
• Monitor process's timeliness in accordance with contractor standards
• Conduct/perform high dollar forecasting research and formulate overall patient health summaries with future health prognosis and projected medical costs
• Provide education to members and their families/caregivers
• Review first level appeal and ensure thorough documentation of each determination and basis for each

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