Medical Claim Reviewer
B
Broadway VenturesHealthcare / Consulting
United States - RemoteFull-TimeMiddle
Salary65,000 USD per year
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Job Details
- Experience
- Two years
- Required Skills
- Microsoft OfficeCompliance
Requirements
- Active, unrestricted RN license in the U.S. and in the state of hire or active compact multistate RN license.
- Associate Degree in Nursing or graduate of an accredited School of Nursing.
- Two years of clinical experience.
- Strong clinical background in managed care, home health, rehabilitation, and/or medical-surgical 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.
Responsibilities
- 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.
- Provide guidance to LPN team members and support non-clinical staff through training and discussions.
- Assist with special projects and additional responsibilities as assigned.
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