Remote Medical Reviewer (Medicare- Home Health)
New
B
Broadway VenturesHealthcare
United StatesFull-TimeMiddle
Salary62,000 - 65,000 USD per year
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Job Details
- Experience
- Two years of clinical experience, plus at least two years in utilization review, medical review, quality assurance, or specific clinical settings.
- Required Skills
- Microsoft OfficeQuality Assurance
Requirements
- Active, unrestricted RN license in the United States
- 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
- Two years of experience in utilization or medical review, quality assurance, or inpatient/outpatient settings
- Strong clinical background in managed care
- 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 competing priorities
- 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 and 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 supporting approval or denial of services
- Educate internal and external teams on medical review processes, coverage determinations, and coding requirements
- Support quality control activities that advance corporate and team objectives
- Assist with special projects and additional duties as assigned
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