Remote Medical Reviewer (Medicare- Home Health)
Core
Review medically complex claims, pre-authorization requests, appeals, and fraud referrals to determine medical necessity and support accurate payment determinations.
Role type
Registered Nurse Medical Reviewer
Builds
Payment determinations and coverage decisions for federal health and defense customers
Domain
Healthcare administration / Medicare / Home Health
Deliverable
production ML models | product features | dashboards & analysis | research | client delivery | infrastructure | physical/clinical work
Required skills
Clinical expertise in managed care and inpatient/outpatient settings, Interpretation of medical review criteria and clinical guidelines, Analytical and decision-making skills, Documentation of rationales for approval or denial
Preferred skills
Experience in utilization review or quality assurance
Technologies
Microsoft Office
Responsibilities
Review complex claims and appeals, Assess payment determinations using clinical guidelines, Evaluate medical necessity and appropriateness, Educate teams on medical review processes, Support quality control activities
Seniority
Mid-level, hands-on IC
