Medical Reviewer I ID-14013
About the position
The Medical Reviewer I position involves performing medical reviews and utilization management for professional, inpatient, or outpatient services. The role requires documenting decisions based on established criteria and providing support for medical claims and utilization practices. The position is remote and is expected to last for a duration of 3 months, with the possibility of extensions.
Remote Moderator, No Degree, $50/hr, Evening, Weekend Job Phone Job, $45/hr, Remote, Night Shift, No Degree Entry Level Phone Job, $40/hr, Remote, No Degree Required Remote Phone Support, $45/hr, Night Job, College Student Remote Customer Support, $45/hr, No Degree, Evening Job Phone Job, $50/hr, Remote, Part-Time, College Student Remote Phone Job, $42/hr, Part-Time, No Experience Required Data Entry, $35/hr, Night Shift, No Degree,?Remote?Job Virtual Assistant, $40/hr, Remote, No Experience, Evening Customer Support, $42/hr, Remote, Part-Time, No Degree Remote Data Entry, $35/hr, No Experience, Evening/Night Job Remote Phone Job, $40/hr, Part-Time, College Student Friendly Phone Support, Remote, $35/hr, No Experience, Part-Time Live Chat Support, Remote, $40/hr, Night Shift, College Student Remote Phone Support, $45/hr, Evening, No Experience Required Customer Support, $42/hr, Weekend Job, Remote, No Degree Phone Job, $45/hr, Remote, Night Shift, No Degree Live Chat Support, $35/hr, Remote, No Experience Required Remote Phone Support, $45/hr, Night Job, College Student Remote Moderator, $45/hr, No Degree, Weekend Job, Part-Time Remote Live Chat, $50/hr, Part-Time, Evening/Night Job Remote Live Chat, $35/hr, College Student, No Experience Remote Phone Job, $45/hr, Part-Time, No Degree Required Data Entry, $35/hr, Night Shift, No Degree,?Remote?Job Virtual Assistant, Remote, $35/hr, Part-Time, Night Shift Remote Live Chat, $42/hr, Weekend, No Degree, Part-Time Remote Live Chat, $35/hr, Part-Time, Evening/Night Job Virtual Assistant, $35/hr, Evening, Remote, College Student Remote Data Entry, $45/hr, No Degree, Night Shift Remote Data Entry, $50/hr, No Experience, Evening/Night Job Phone Support, Remote, $35/hr, No Experience, Part-Time Phone Job, $35/hr, Remote, Part-Time, College Student Virtual Assistant, $40/hr, Remote, Night Shift, No Experience Remote Moderator, No Degree, $50/hr, Evening, Weekend Job Remote Data Entry, $40/hr, No Degree, Night Shift Weekend Customer Support, $42/hr, Remote, College Student Phone Job, $35/hr, Remote, Part-Time, College Student Remote Phone Job, $35/hr, College Student, Night Shift Remote Customer Support, $50/hr, Night Shift, No Degree Remote Data Entry, $40/hr, No Degree, Night Shift Live Chat Support, $40/hr, Part-Time, Remote, No Degree Remote Moderator, $45/hr, No Degree, Weekend Job, Part-Time Virtual Assistant, $50/hr, Weekend, No Degree, Remote Phone Support, Remote, $35/hr, No Experience, Part-Time Part-Time Data Entry, $40/hr, Remote, College Student Friendly Customer Support, $35/hr, Remote, Evening/Night Job, No Degree Virtual Assistant, Remote, $50/hr, Part-Time, Night Shift Remote Moderator, $42/hr, Weekend, No Experience Required Data Entry, $45/hr, Remote, Night Shift, College Student Job Phone Job, $35/hr, Remote, No Degree, Part-Time, Weekend Remote Moderator, $42/hr, College Student, Weekend Job Remote Live Chat, $35/hr, College Student, No Experience Remote Phone Support, $40/hr, Evening, No Experience Required Virtual Assistant, $35/hr, Part-Time, Remote, Weekend Job Remote Data Entry, $50/hr, No Experience, Evening/Night Job Customer Support, No Degree, $40/hr, Remote, Weekend Job Live Chat Support, $50/hr, Remote, Night Shift, No Degree Phone Support, $45/hr, Remote, No Experience, Evening Job Entry-Level Remote Data Entry, $50/hr, Evening Job Phone Support, $50/hr, Weekend, Remote, No Experience Remote Phone Job, $40/hr, Part-Time, No Experience Required Remote Virtual Assistant, $40/hr, Evening, Part-Time Job Data Entry, No Experience, $35/hr, Remote, College Student Phone Support, $45/hr, Remote, No Experience, Evening Job Remote Moderator, $40/hr, College Student Friendly, Part-Time Virtual Assistant, $50/hr, Evening, Remote, College Student Virtual Assistant, No Experience, $42/hr, Remote, Part-Time Phone Support, Remote, $35/hr, No Experience, Night Shift Customer Support, $42/hr, Remote, Part-Time, No Degree Remote Phone Job, $35/hr, College Student, Night Shift Customer Support, $42/hr, Weekend Job, Remote, No Degree Remote Moderator, $40/hr, Weekend, No Degree, Part-Time Data Entry, $35/hr, Remote, Evening Job, College Student Live Chat Support, $35/hr, Remote, No Experience Required Remote Phone Support, $40/hr, Night Job, College Student Remote Moderator, $50/hr, No Degree, Weekend, Part-Time Data Entry, $35/hr, Remote, Evening Job, College Student Remote Moderator, $40/hr, College Student, Weekend Job Virtual Assistant, $35/hr, Part-Time, Remote, Weekend Job Virtual Assistant, $35/hr, Evening, Remote, College StudentResponsibilities
- Perform medical claim reviews and make reasonable charge payment determinations.
- Monitor process timeliness in accordance with contractor standards.
- Perform authorization processes, ensuring coverage for appropriate medical services within benefit and medical necessity guidelines.
- Utilize allocated resources to back up review determinations.
- Review interdepartmental requests and medical information in a timely manner to complete the utilization process.
- Conduct high dollar forecasting research and formulate overall patient health summaries with future health prognosis and projected medical costs.
- Perform screenings/assessments and determine risk via telephone.
- Review and determine eligibility, level of benefits, and medical necessity of services.
- Provide education to members and their families/caregivers.
- Review first level appeals and ensure thorough documentation of each determination and basis for each.
- Conduct necessary research to make thorough and accurate determinations.
- Educate internal/external staff regarding medical reviews, medical terminology, coverage determinations, and coding procedures.
- Respond accurately and timely with appropriate documentation to members and providers on all rendered determinations.
- Participate in quality control activities in support of corporate and team-based objectives.
Requirements
- Bachelor's degree in Social Work or Graduate of an Accredited School of Licensed Practical Nursing or Licensed Vocational Nursing.
- 2 years of clinical experience.
- Active, unrestricted LPN/LVN licensure from the United States and in the state of hire, or active compact multistate unrestricted LPN license as defined by the Nurse Licensure Compact (NLC), or active, unrestricted LBSW licensure from the United States and in the state of hire.
Nice-to-haves
- Associate Degree in Nursing or Graduate of an Accredited School of Nursing.
- Active, unrestricted RN licensure from the United States and in the state of hire, or active compact multistate unrestricted RN license as defined by the Nurse Licensure Compact (NLC).
Benefits
- ACA compliant health benefits
- Dental insurance
- Vision insurance
- Accident insurance
- Critical illness insurance
- Voluntary life insurance
- Hospital indemnity insurance
- Commuter benefits
- 401K plan with matching
- Referral bonus program
- Unpaid leave
- Paid sick leave when required by law
