Reviewer I, Medical

Title:

Reviewer I, Medical Location:

Columbia SC, remote after 1-2 week onsite training

Duration:

4 months with possible extension

Schedule:

Monday-Friday, 8:30 AM - 5:00

PM Job Summary:

Performs medical reviews using established criteria sets and/or performs utilization management of professional, inpatient or outpatient, facility benefits or services, and appeals. Documents decisions using indicated protocol sets or clinical guidelines. Provides support and review of medical claims and utilization practices. Day to

Day:

80% Performs medical claim reviews and utilization review activities including authorization reviews, medical necessity determinations, eligibility and benefit reviews, charge payment determinations, first-level appeals, and coverage reviews. Reviews medical information and interdepartmental requests to support utilization management processes. Conducts screenings and risk assessments via telephone, develops patient health summaries, performs forecasting research when applicable, and provides education to members and caregivers. Documents all determinations and supporting rationale in accordance with established clinical guidelines and contractor standards. 10% Educates internal and external staff regarding medical reviews, medical terminology, coverage determinations, coding procedures, and utilization review practices. Responds accurately and timely to members and providers with appropriate supporting documentation. 10% Participates in quality control activities supporting corporate and team objectives. Attends required training and contributes to continuous process improvement initiatives.

Job Requirements:

Required Education:

Bachelor's Degree in Social Work, OR Graduate of an Accredited School of Licensed Practical Nursing (LPN) or Licensed Vocational Nursing (LVN).

Required Experience:

2 years of clinical experience.

Required Licenses and Certificates:

Active, unrestricted LPN/LVN license in the state of hire, OR Active compact multistate unrestricted LPN license as defined by the Nurse Licensure Compact (NLC), OR Active, unrestricted Licensed Bachelor Social Worker (LBSW) license in the state of hire.

Preferred Education:

Associate Degree in Nursing OR Graduate of an Accredited School of Nursing.

Preferred Licenses and Certificates:

Active, unrestricted RN license in the state of hire, OR active compact multistate unrestricted RN license as defined by the Nurse Licensure Compact (NLC).