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

• Performs 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
• Makes reasonable charge payment determinations based on clinical/medical information and established criteria/protocol sets
• 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.
• 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 III – Home Health and Hospice

• 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

Medical Reviewer jobs in Texas

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Medical Reviewer II

Medical Reviewer III – Home Health and Hospice

Medical Reviewer III – Home Health and Hospice