Role Name: Medical Reviewer II Location: Columbia, SC 29229 Work Environment: Onsite Schedule: Mon - Fri, 8am - 4:30pm. Contract length: 3 months assignment with possible extension Job Summary: Duties/About the role: Performs medical reviews using clinical/medical information provided by physicians/providers and established criteria/protocol sets or clinical guidelines. Documents decisions using indicated protocol sets or clinical guidelines. Provides support and review of medical claims and utilization practices. Day to Day: 70% Performs medical claim reviews for one or more of the following: claims for medically complex services, services that require preauthorization/predetermination, requests for appeal or reconsideration, referrals for potential fraud and/or abuse, correct coding for claims/operations. Makes reasonable charge payment determinations based on clinical/medical information and established criteria/protocol sets or clinical guidelines. Determines medical necessity and appropriateness and/or reasonableness and necessity for coverage and reimbursement. Monitors processs timeliness in accordance with contractor standards. Documents medical rationale to justify payment or denial of services and/or supplies. 20% Educates internal/external staff regarding medical reviews, medical terminology, coverage determinations, coding procedures, etc. in accordance with contractor guidelines. 10% Participates in quality control activities in support of the corporate and team-based objectives. Provides guidance, direction, and input as needed to LPN team members. Provides education to non-medical staff through discussions, team meetings, classroom participation, and feedback. Assists with special projects and specialty duties/responsibilities as assigned by management. Job Requirements: Required Education: Associate Degree - Nursing or Graduate of an accredited School of Nursing. Required Work Experience: 2 years clinical experience. Required Training: Active RN licensure in state hired, OR, active compact multistate RN license as defined by the Nurse Licensure Compact (NLC). Spectraforce Technologies
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