Medical Reviewer

• 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, 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 and 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

Medical Reviewer II – Prior-Auth A/B MAC

• Evaluate medical records and prepare concise clinical summaries
• Provide independent medical opinions in response to specific questions posed by clients
• Conduct thorough medical record reviews on orthopedic spine conditions, injuries, and treatments
• Participate in peer-to-peer discussions when necessary
• Answer client-specific questions regarding orthopedic spine diagnoses, treatment plans, and surgical interventions
• Apply current clinical guidelines and standards of care to all reviews

Orthopedic Spine Surgeon – Medical Reviewer

• 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

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Medical Reviewer II – Prior-Auth A/B MAC

Medical Reviewer II – Prior-Auth A/B MAC

Orthopedic Spine Surgeon – Medical Reviewer

Complex Claims Clinical Reviewer