Medical Reviewer, Medicare

Job Description: • Conducting pre- and post-payment medical reviews to ensure compliance with established clinical criteria and guidelines • Review medically complex claims, pre-authorization requests, appeals, and fraud/abuse referrals • Assess payment determinations using clinical information and established guidelines • Evaluate medical necessity, appropriateness, and reasonableness for coverage and reimbursement • Provide clear, well-documented rationales for service approvals or denials • Educate internal and external teams on medical review processes, coverage determinations, and coding requirements • Support quality control activities to meet corporate and team objectives • Assist with special projects and additional responsibilities as assigned Requirements: • Active, unrestricted RN license in the U.S. and in the state of hire OR • Active compact multistate RN license (as defined by the Nurse Licensure Compact) • Associate Degree in Nursing OR • Graduate of an accredited School of Nursing • Two years of clinical experience plus at least two years in one of the following: • Inpatient/Outpatient settings (i.e. medical-surgical, rehabilitation, SNF, etc..) • Utilization/Medical Review • Quality Assurance • Strong clinical background in managed care and/or inpatient/outpatient settings • Ability to interpret and apply medical review criteria and clinical guidelines • Proficiency in Microsoft Office and word processing software • Strong analytical, organizational, and decision-making skills • Ability to work independently while managing priorities effectively • Excellent customer service, communication, and critical thinking skills • Ability to handle confidential information with discretion Benefits: • High-speed internet (non-satellite) and a private, lockable home office • All necessary equipment to perform your job effectively, including but not limited to a desktop computer, dual monitors, a headset, an ethernet cable, and additional accessories as needed. Apply tot his job Apply To this Job