Medical Reviewer

• Perform medical claim reviews 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.
• 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

Reviewer II, Medical

• Perform medical claim reviews for claims requiring preauthorization or appeals
• Determine medical necessity and appropriateness for coverage and reimbursement
• Document medical rationale for payment or denial of services
• Educate staff on medical reviews, coverage determinations, and coding procedures
• Participate in quality control activities

• Performs medical reviews using established criteria sets and/or performs utilization management of professional, inpatient or outpatient, facility benefits or services, and appeals.
• Documents decisions using indicated protocol sets or clinical guidelines.
• Provides support and review of medical claims and utilization practices.
• May provide any of the following in support of medical claims review and utilization review practices: Performs medical claim reviews and makes a reasonable charge payment determination.
• Monitors process's timeliness in accordance with contractor standards.
• Performs authorization process, ensuring coverage for appropriate medical services within benefit and medical necessity guidelines.
• Utilizes allocated resources to back up review determination.
• Reviews interdepartmental requests and medical information in a timely/effective manner in order to complete utilization process.
• May conduct/perform high dollar forecasting research and formulate overall patient health summaries with future health prognosis and projected medical costs.
• Performs screenings/assessments and determines risk via telephone.
• Reviews/determines eligibility, level of benefits, and medical necessity of services and/or reasonableness and necessity of services.
• Provides education to members and their families/caregivers.
• Reviews first level appeal and ensures utilization or claim review provides thorough documentation of each determination and basis for each.
• Conducts research necessary to make thorough/accurate basis for each determination made.
• Educates internal/external staff regarding medical reviews, medical terminology, coverage determinations, coding procedures, etc. in accordance with contractor guidelines.
• Responds accurately and timely with appropriate documentation to members and providers on all rendered determinations.
• Participates in quality control activities in support of the corporate and team-based objectives.

Medical Reviewer I

• Acts as Team Lead for specialty programs, medical review, utilization management, and case management areas.
• Provides leadership/guidance/direction/training to staff.
• Maintains a working knowledge of unit functions and the ability to interpret to new hires.
• Acts as a resource for staff/external entities troubleshooting as well as resolving issues.
• Keeps manager informed of any problems/issues that need resolving.
• Assists management with monitoring workflow and workloads.
• Participates in departmental quality reviews.
• Gives/receives feedback regarding medical review decision making and technical claims processing issues.
• Participates in compliance initiatives and other directed activities.
• Participates/oversees special projects as requested by management.

Senior Medical Reviewer

• Functions as team leader/senior-level Medical Reviewer.
• Provides leadership/guidance/direction/training to staff.
• Maintains working knowledge of unit functions and ability to interpret to new hires, department interworkings and workflow.
• Acts as resource for staff/external entities troubleshooting as well as resolving issues.
• Keeps manager informed of any problems/issues that need resolving.
• Assists management with monitoring workflow and workloads (including reassignment of work to meet timelines, redirecting work intake source to balance workloads), reporting, and addressing aging issues.
• Participates in departmental quality reviews.
• Follows process to ensure quality plan is adhered to and communicated to all parties.
• Gives/receives feedback regarding medical review decision making and technical claims processing issues.
• Ensures that quality work instructions/forms/documents are developed/revised as needed.
• Provides quality service and communicates effectively with external/internal customers in response to inquiries.
• Obtains information from internal departments, providers, government, and/or private agencies, etc. to resolve discrepancies/problems.
• Participates in compliance initiatives and other directed activities.
• Participates/oversees special projects as requested by management.

Senior Medical Reviewer – Behavioral Health Focused

• 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

RN Medical Reviewer II

• Acts as Team Lead for specialty programs, medical review, utilization management, and case management areas by providing assistance and support to unit supervisor/manager by giving direction/guidance/training to staff.
• Ensures appropriate levels of healthcare services are provided.
• Functions as a team leader/senior-level Medical Reviewer.
• Provides leadership/guidance/direction/training to staff.
• Maintains a working knowledge of unit functions and the ability to interpret to new hires, department interworking, and workflow.
• Acts as a resource for staff/external entities troubleshooting as well as resolving issues.
• Keeps manager informed of any problems/issues that need resolving.
• Assists management with monitoring workflow and workloads (including reassignment of work to meet timelines, redirecting work intake source to balance workloads), reporting, and addressing aging issues.
• Participates in departmental quality reviews.
• Follows a process to ensure quality plan is adhered to and communicated to all parties.
• Gives/receives feedback regarding medical review decision making and technical claims processing issues.
• Ensures that quality work instructions/forms/documents are developed/revised as needed.
• Provides quality service and communicates effectively with external/internal customers in response to inquiries.
• Obtains information from internal departments, providers, government, and/or private agencies, etc. to resolve discrepancies/problems.
• Participates in compliance initiatives and other directed activities.
• Participates/oversees special projects as requested 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
• 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

RN 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, and correct coding for claims/operations
• Make reasonable payment determinations based on clinical medical information and established criteria/protocol sets or clinical guidelines
• Determines medical necessity, 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 and external staff regarding medical reviews, medical terminology, coverage determinations, coding procedures, etc. in accordance with contractor guidelines
• Participate in quality control activities supporting 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 and responsibilities as assigned by management

Medical Reviewer II

• 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.

• 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.

• 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.

Medical Reviewer jobs in South Carolina

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Reviewer II, Medical

Reviewer II, Medical

Medical Reviewer I

Senior Medical Reviewer

Senior Medical Reviewer – Behavioral Health Focused

RN Medical Reviewer II

Senior Medical Reviewer

RN Medical Reviewer III

Medical Reviewer II

Medical Reviewer I

RN Medical Reviewer III

RN Medical Reviewer III