Medical Reviewer II

Job Description:

• Perform medical claim reviews for medically complex services, preauthorization/predetermination requests, appeals or reconsiderations, potential fraud and/or abuse referrals, and correct coding for claims/operations
• Make payment determinations using clinical medical information and established criteria, protocol sets, or clinical guidelines
• Determine medical necessity, appropriateness, and reasonableness for coverage and reimbursement
• Monitor process timeliness according to contractor standards
• Document medical rationale supporting payment or denial of services and supplies
• Educate internal and external staff on medical reviews, medical terminology, coverage determinations, and coding procedures
• Participate in quality control activities supporting corporate and team-based objectives
• Provide guidance, direction, and input to LPN team members
• Educate non-medical staff through discussions, team meetings, classroom participation, and feedback
• Assist with special projects and specialty duties assigned by management

Requirements:

• Active RN licensure in the state hired, or active compact multistate RN license under the Nurse Licensure Compact (NLC)
• Associate degree in Nursing or graduation from an accredited School of Nursing
• Two years of clinical experience as an RN
• Working knowledge of word processing software
• Ability to work independently, prioritize effectively, and make sound decisions
• Good judgment skills
• Demonstrated customer service and organizational skills
• Demonstrated oral and written communication skills
• Analytical or critical thinking skills
• Ability to handle confidential or sensitive information with discretion
• Microsoft Office proficiency
• Acute care experience required
• Ability to use multiple Windows-based programs simultaneously preferred
• Three years of varied RN nursing experience, including Medical/Utilization Review, Quality Assurance, Emergency, Critical Care, or Medical/Surgical experience, strongly preferred
• Medicare or claims experience a plus
• Critical care experience preferred
• Medical review/utilization review experience preferred

Benefits:

• Subsidized health plans
• Dental and vision coverage
• 401k retirement savings plan with company match
• Life Insurance
• Paid Time Off (PTO)
• On-site cafeterias and fitness centers in major locations
• Education Assistance
• Service Recognition
• National discounts to movies, theaters, zoos, theme parks and more
• Reasonable accommodations for disabilities, pregnancy-related conditions, and sincerely held religious beliefs
• Pay differential coverage for full-time employees in the National Guard or Reserves called to active duty