Medical Claim Reviewer (CGS, DMEC-B)
Core
Conduct pre- and post-payment medical reviews to assess medical necessity, appropriateness, and reimbursement eligibility for complex claims, pre-authorizations, and appeals.
Role type
Registered Nurse (RN) Medical Reviewer
Builds
Medical review decisions and documentation for government and private sector clients
Domain
Healthcare / Insurance / Managed Care
Deliverable
production ML models | product features | dashboards & analysis | research | client delivery | infrastructure | physical/clinical work
Required skills
Clinical expertise in managed care, home health, rehabilitation, or medical-surgical settings; Ability to interpret clinical guidelines; Analytical and decision-making skills; Proficiency in Microsoft Office
Preferred skills
Experience with fraud/abuse referrals; Training and guidance of LPN team members
Technologies
Microsoft Office
Responsibilities
Review medically complex claims, pre-authorization requests, appeals, and fraud/abuse referrals; Assess payment determinations using clinical information; Evaluate medical necessity and reasonableness for coverage; Provide documented rationales for service approvals or denials; Support quality control activities; Educate teams on medical review processes and coding requirements
Seniority
Mid-level, hands-on IC