Medical Reviewer (Remote)
Core
Review medical claims (Radiology, Ambulance, PT, Surgical) to determine medical necessity, coverage, and payment using clinical guidelines and physician data.
Role type
Senior IC medical reviewer (utilization review)
Builds
Medical claims decisions and utilization practices for government and private sector clients
Domain
Healthcare / Insurance / Utilization Review
Required skills
Active unrestricted RN license, Medicare guidelines knowledge, clinical criteria/protocol sets, coding review, fraud/abuse detection, quality control, documentation, staff education
Preferred skills
BSN, 5+ years clinical experience, Medicare Part B claims expertise, database software proficiency
Technologies
Microsoft Office, EUA/system access
Responsibilities
Review complex medical claims, preauthorizations, appeals, and reconsiderations; document medical rationale for payment/denial; educate staff on terminology and coding; guide LPN team members; participate in quality control activities.
Seniority
Mid-Senior level (2+ years clinical + 2 years review experience required)