Reviewer I, Medical

Duties

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.

80% Supports medical claims review and utilization review practices:

Performs medical claim reviews and makes reasonable charge payment determinations.

Monitors process timeliness in accordance with contractor standards.

Performs authorization process, ensuring coverage for appropriate medical services within benefit and medical necessity guidelines.

Utilizes allocated resources to back up review determinations.

Reviews interdepartmental requests and medical information in a timely and effective manner to complete utilization process.

May conduct high-dollar forecasting research and formulate overall patient health summaries with future health prognosis and projected medical costs.

Performs screenings/assessments and determines risk via telephone.

Reviews and determines eligibility, level of benefits, and medical necessity of services and/or reasonableness and necessity of services.

Provides education to members and their families/caregivers.

Reviews first level appeal and ensures utilization or claim review provides thorough documentation of each determination and basis for each.

Conducts research necessary to make thorough and accurate basis for each determination made.

10% Educates internal/external staff regarding medical reviews, medical terminology, coverage determinations, coding procedures, etc. in accordance with contractor guidelines. Responds accurately and timely with appropriate documentation to members and providers on all rendered determinations.

10% Participates in quality control activities in support of the corporate and team-based objectives and participates in all required training.

Skills
Required Skills and Abilities

Working knowledge of word processing software.

Good judgment skills.

Demonstrated customer service and organizational skills.

Demonstrated proficiency in spelling, punctuation, and grammar skills.

Analytical or critical thinking skills.

Ability to handle confidential or sensitive information with discretion.

Ability to remain in a stationary position and operate a computer.

Required Software and Tools

Microsoft Office.

Preferred Skills and Abilities

Working knowledge of spreadsheet and database software.

Demonstrated oral and written communication skills.

Ability to persuade, negotiate, or influence others.

Preferred Software and Others Tools

Knowledge of Microsoft Excel, Access, or other spreadsheet/database software.

Work Environment
Typical office environment with some travel between office buildings.

#J-18808-Ljbffr