Medical Reviewer

Key Responsibilities:

• Perform medical reviews using clinical/medical information and established criteria/protocol sets or clinical guidelines.
• Document decisions and provide support for medical claims, including preauthorization, appeals, and fraud referrals.
• Determine medical necessity and appropriateness for coverage and reimbursement.

Qualifications:

• Associate Degree in Nursing or four-year health-related degree, or graduate of accredited School of Nursing.
• Two years clinical experience plus two years utilization/medical review, quality assurance, or home health experience.
• Active, unrestricted RN licensure or equivalent certification in the state of hire.

Work Environment:

• Typical office environment with potential for work-from-home arrangements.
• May involve travel from home to office and remaining in a stationary position operating a computer.