Medical Reviewer

• To ensure the appropriate utilization of services act as an advocate for our members and to ensure the highest quality and cost-effective care.
• Reviews Provider request for relevant and complete supporting documentation and requests for missing or additional documentation from providers per guidelines.
• Utilizing clinical guidelines approved by the Utilization Management Committee (UMC), the URN has the authority to authorize services or procedures.
• Verifies accuracy of codes and services and applies them accurately with appropriate documentation.
• Ensures regulatory guidelines are met for timeliness and use of medical review criteria.
• Acts with honor and integrity, serving as a role model for the company while establishing and maintaining professional relationships with Providers and office staff.
• Complies with HIPAA requirements and all Evolent policies and procedures.
• Performs other duties as assigned including and not limited to develop report data elements.

Clinical Reviewer, Radiation Therapy

• Conducts reviews of clinical interactions and clinical documentation
• Collects data following established procedures and analyzes findings for purposes of continuous quality improvement and for internal and external reporting
• Interacts with multiple stakeholders internally and externally
• Provides clinical reviews of Quality of Care (QOC) and Critical/Adverse incidents related to clinical services
• Audits and reviews case manager and provider clinical documentation and telephone interactions against regulations, accreditation standards and contract requirements
• Conducts ongoing activities which monitor established quality of care standards in the participating provider network and for care managers
• Evaluates level of patient safety risk and need for follow-up actions per policies
• Prepares monthly performance reports with assistance from Reporting and Analytics unit
• Presents findings at provider and customer meetings as needed
• Assists in the planning and implementation of activities to improve delivery of services and quality of care including the development and coordination of in-service education programs for providers and care managers
• Responsible for auditing as well as validating internal audit results and/or corrective action plans

Quality Clinical Reviewer

• A Clinical Reviewer and Tele-Services Clinician is responsible for reviewing medical records, patient information, and treatment plans to ensure compliance with clinical guidelines and standards.
• Provide tele-services, such as telemedicine or teletherapy, to patients remotely.
• Applies MedRisk's telerehabilitation and consultation program inclusion guidelines to assigned cases to determine eligibility and appropriateness.
• Execute PT/OT evaluation and treatment consistent with telerehabilitation clinical guidelines.
• Document telerehabilitation visits and consultation in a manner consistent with company policies and department procedures.
• Perform telephonic outreach to patient, in-clinic provider, payor and physician when needed, or as requested.
• Document all communications with case stakeholders (adjusters, case managers, in-clinic providers).
• Initiates review for requested service upon system referral.
• Reviews each case and formulates recommendations through use of established medical criteria and clinical judgment.
• Contacts the treating practitioner for additional information or clarification, when necessary.
• Conducts ongoing review(s) of active cases regarding the need for continued services or treatment.
• Complies with all established policies and procedures.
• Attends meetings and trainings.

Clinical Reviewer

• Support most complex medical record audit programs
• Generate concise in-depth reporting and analysis to track performance
• Provide Provider Pre Pay production and progress reports
• Recommend process or procedure changes
• Demonstrate leadership ability
• Identify knowledge gaps and provide training opportunities
• Serve as a primary resource for provider escalation support
• Maintain a working knowledge of all state and federal laws, rules, and billing guidelines

Medical Coding Reviewer III, CPC, RHIT/RHIA Required

• Conducts reviews of clinical interactions and clinical documentation including reviews of case management records and provider treatment records.
• Collects data following established procedures and analyzes findings for purposes of continuous quality improvement and for internal and external reporting.
• Interacts with multiple stakeholders internally and externally.
• Provides clinical reviews of Quality of Care (QOC) and Critical/Adverse incidents related to clinical services.
• Audits and reviews case manager and provider clinical documentation and telephone interactions against regulations, accreditation standards and contract requirements.
• Conducts ongoing activities which monitor established quality of care standards in the participating provider network and for care managers.
• Evaluates level of patient safety risk and need for follow-up actions per policies.
• Collects, analyzes and prepares clinical record information for projects related to assessing the efficiency, effectiveness and quality of the delivery of managed care services.
• Prepares monthly performance reports with assistance from Reporting and Analytics unit.
• Presents findings at provider and customer meetings as needed.
• Assists in the planning and implementation of activities to improve delivery of services and quality of care including the development and coordination of in-service education programs for providers and care managers.
• Responsible for auditing as well as validating internal audit results and/or corrective action plans.

• 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

• Review acute and post-acute authorizations for medical necessity using InterQual guidelines
• Collaborate with case managers, physicians, and medical directors to ensure appropriate levels of care
• Participate in team meetings, educational activities, and interrater reliability testing to maintain review consistency and professional growth
• Ensure compliance with federal, state, and accreditation standards, and identify opportunities to enhance communication or processes
• Utilize knowledge of resources available in the healthcare system to assist physicians and patients effectively
• Perform other job duties as assigned

Authorization Management Clinical Reviewer

• Perform clinical reviews of medical records and other documentation to validate issues of claims coding accuracy, medical necessity, and the appropriateness of treatment settings and services delivered.
• Report to the Payment Assurance Senior Manager and support a culture and work environment that promotes and inspires an active, continuous improvement philosophy regarding products and services in line with our company mission.
• Audits and analyzes neonatal intensive care unit (NICU) claims according to ICD-10 coding principles and clinical guidelines.
• Analysis of claims data to optimize reimbursement by ensuring that the diagnosis codes, procedure codes, and supporting documentation accurately support the service rendered.
• Ensure claims analysis complies with ethical coding standards, guidelines, and regulatory requirements.
• Responsible for performing clinical reviews of medical records and other documentation to validate issues of claims coding accuracy, medical necessity, and the appropriateness of treatment settings and services delivered.
• Utilize Clinical Review Tools and EMR Systems.
• Research reimbursement regulations for claim payment compliance to support and validate audit findings.
• Assist with the development of claims audit process documentation, including workflow diagrams, policies and procedures, and standard operating procedures.
• Detect discrepancies in provider billing and recommend adjustments to ensure proper reimbursement.

Clinical RN Chart Reviewer, CIC or CCS certified

• 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

• Provide operational support to the Medical Review Manager and the Medical Review Staff in managing production related to claims determinations and review
• Serve as a critical component in meeting our mission of providing excellent services to our clients
• Review and analyze sampled Medicare claims using associated medical records
• Make payment determinations based on coverage, coding, utilization of services and practice guidelines
• Perform third-level Medical Review in determination of claims payment review
• Conduct in-depth claims analysis utilizing ICD-9-CM, ICD-10-CM, CPT-4, and HCPCS Level II coding principles
• Conducts medical record audits to determine the medical necessity and/or appropriateness of medical treatment using CMS and other national guidelines
• Assist with training to integral staff for special studies as well as regular project claims review

Medical Reviewer V

• 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

• Responsible for supporting and assisting all cardiology administrative and clinical utilization management and quality improvement functions
• Act as a clinical liaison to providers, clients, and patients
• Maintain and operate Guideline Directed Medial Therapy
• Communicate clinical information needs to ordering providers
• Prep cases for P2P discussions
• Coordinate with UM staff for communication of clinical decisions
• Complete UM projects and participate in site visit reviews
• Serve as subject matter expert in assigned meetings

Clinical Reviewer, Electrophysiology NP/PA

• 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

• Evaluating requests for authorization of clinical services from physician offices and/or imaging centers
• Comparing requests against established clinical protocols and authorizing services or referring requests for expert clinical review
• Reviewing clinical information submitted by providers and making decisions to issue a review determination
• Maintaining current departmental standards related to productivity
• Providing outstanding customer service ensuring callers receive the highest possible service
• Assisting team members with questions and participating in team meetings

Telephonic Registered Nurse Clinical Reviewer

• 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

• Reviews medical bills and documentation according to guidelines and RW policies and procedures.
• Determines if treatment is related and necessary to the covered injury.
• Advises reimbursement recommendations are appropriate.
• Provides customer service to adjusters, providers, and claimants regarding bill review.
• Assesses appropriateness and duration of care provided, for possible utilization review.
• Recommends independent medical evaluations (IME) to adjusters when necessary.
• Act as a resource to other staff members to facilitate completion of a quality product.
• Use appropriate reference material as necessary to perform professional review.
• Meets company productivity standards.
• Meets company quality standards.

Medical Review Specialist

• Responsible for processing medical necessity reviews for appropriateness of authorization for health care services
• Assisting with discharge planning activities (i.e. DME, home health services)
• Care coordination for members
• Monitoring the delivery of healthcare services
• Complete prospective, concurrent and retrospective reviews
• Identify, document, communicate, and coordinate care
• Engage with medical director when additional clinical expertise is needed
• Maintain knowledge of regulations governing CareSource
• Identify and refer quality issues to Quality Improvement
• Provide guidance to non-clinical staff
• Provide guidance and support to LPN clinical staff as appropriate
• Assist Team Leader with special projects or research
• Perform any other job related duties as requested.

Medical Reviewer jobs in United States

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Clinical Reviewer, Radiation Therapy

Quality Clinical Reviewer

Clinical Reviewer

Medical Coding Reviewer III, CPC, RHIT/RHIA Required

Quality Clinical Reviewer

Medical Reviewer II

Authorization Management Clinical Reviewer

Clinical RN Chart Reviewer, CIC or CCS certified

Medical Reviewer III – Home Health and Hospice

Medical Reviewer III – Home Health and Hospice

Medical Reviewer V

Reviewer II, Medical

Reviewer II, Medical

Clinical Reviewer, Electrophysiology NP/PA

Medical Reviewer I

Telephonic Registered Nurse Clinical Reviewer

Senior Medical Reviewer

Senior Medical Reviewer – Behavioral Health Focused

Medical Review Specialist

Clinical Care Reviewer II – Unrestricted Massachusetts RN License