Medical Reviewer III - Home Health and Hospice
New
United States, 8:00AM-4:30PM CST (start times between 6:00am - 9:00am)Full-TimeSenior
Salary51,107 - 97,729 USD per year
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Job Details
- Experience
- 2 years clinical plus 1 year utilization/medical review, quality assurance, or home health, OR 3 years clinical.
- Required Skills
- Microsoft OfficeQuality Assurance
Requirements
- Associate's degree in a job-related field or graduate of an accredited School of Nursing.
- Active, unrestricted RN licensure from the United States and in the state of hire, or current active compact multistate unrestricted RN license.
- 2 years clinical experience plus 1 year utilization/medical review, quality assurance, or home health experience; OR 3 years clinical experience.
- Working knowledge of managed care and health care delivery systems.
- Strong clinical experience in home health, rehabilitation, or broad medical-surgical areas.
- Knowledge of specific criteria/protocol sets and their application.
- Proficiency with Microsoft Office suite.
- Strong analytical and critical thinking skills.
- Ability to work independently, prioritize tasks, and make sound decisions.
- Demonstrated oral and written communication skills.
- Ability to handle confidential or sensitive information with discretion.
Responsibilities
- Perform medical claim reviews for medically complex services, preauthorization requests, appeals, and fraud referrals.
- Make payment determinations based on established clinical criteria, protocol sets, and medical guidelines.
- Determine medical necessity, appropriateness, and reasonableness for coverage and reimbursement.
- Document medical rationale to justify service payment or denial.
- Educate internal and external staff regarding medical reviews, terminology, and coding procedures.
- Participate in quality control activities and provide guidance to LPN team members.
- Assist with special projects and specialty duties as assigned by management.
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