Reviewer

• Coordinate, integrate, and monitor utilization of behavioral health or physical health services for members
• Perform pre-service, concurrent, and post-service clinical reviews to determine appropriateness and medical necessity of requested services
• Apply clinical review criteria, guidelines, medical policies, contractual benefits, and State and Federal Mandates
• Plan, implement, and document utilization management activities
• Obtain clinical information from members and providers and interact with treating physicians and other care providers
• Refer appropriate cases and potential quality-of-care or utilization issues to the Medical Director
• Collaborate with hospitals, home care, care management, and other providers to prevent gaps in care
• Act as a resource and liaison to the provider community
• Perform pricing, coding, and claims research when assigned
• Meet departmental timeliness, production, metrics, audit, regulatory, and accreditation requirements
• Assist with training and special projects
• Participate in rotating on-call schedules and work additional hours as needed
• Level II: suggest process improvements, mentor staff, manage complex assignments, and participate in committees
• Level III: provide leadership, resolve escalated issues, update procedures, mentor staff, support orientation and training, and provide supervisor backup

Utilization Management Reviewer assessing healthcare service necessity for Excellus BCBS members

Utilization Management Reviewer, RN

Utilization Management Reviewer assessing behavioral and physical healthcare service necessity for Excellus BCBS members. Coordinating clinical reviews, providers, care management, and regulatory compliance.

• Use rubrics and supplemental information to provide fair and consistent evaluations with encouraging, specific, and actionable feedback
• Maintain an in-depth knowledge of every component of curriculum within assigned workload
• Swiftly respond to student outreach and return evaluations to students within 48 hours of submission
• Work with Goal Lead to provide proactive outreach to students in need of academic assistance
• Participate in Reviewer online community
• Support academic integrity validation and processing potential violations
• Participate in quality assurance processes and project improvement activities, as needed

Reviewer evaluating student projects at Southern New Hampshire University

Reviewer responsible for evaluating student project submissions at Southern New Hampshire University. Provide actionable feedback and ensure academic integrity in evaluations.

• In-person interview may be required during the hiring process
• Manage relationships with internal and external customers/vendors

MD Appraisal Reviewer managing automobile appraisals at Mercury Insurance

MD Appraisal Reviewer

MD Appraisal Reviewer managing automobile appraisals at Mercury Insurance. Collaborating with internal and external teams to ensure efficient processes and accurate valuations.

• Review and edit AI critique of writing samples using professional criteria
• Articulate evaluation methods for writing quality in your domain
• Participate in live workshops to explain edits

Expert Reviewer providing writing critiques for AI feedback tools

Expert Reviewer – Short-term Research Project

Expert Reviewer providing professional writing critiques for AI tools. Collaborating on creating personalized feedback templates for users.

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Utilization Management Reviewer, RN

Reviewer

MD Appraisal Reviewer

Expert Reviewer – Short-term Research Project