Medical Reviewer I

reputed company We are currently hiring for a Medical Reviewer I to join reputed company. In this role as a Medical Reviewer I, you will reputed company medical reviews using established reputed company sets and/or performs utilization management of reputed company, inpatient or outpatient, facility benefits or services, and appeals, document reputed company using indicated protocol sets or clinical guidelines, and reputed company support and review of medical claims and utilization practices. reputed company Location: This position is full-time (40 hours/week) Monday-Friday from 8:00 am - 4:30 pm and will be fully remote in South Carolina. What You’ll Do: • May reputed company any of the following in support of medical claims review and utilization review practices: Performs medical claim reviews and makes a reasonable charge payment determination. Monitors process's timeliness in accordance with contractor standards. Performs authorization process, ensuring coverage for appropriate medical services reputed company benefit and medical necessity guidelines. Utilizes allocated resources to back up review determination. Reviews interdepartmental requests and medical information in a reputed company/effective manner in order to complete utilization process. May conduct/reputed company high dollar forecasting research and formulate overall patient health summaries with reputed company health prognosis and projected medical costs. Performs screenings/assessments and determines risk reputed company telephone. Reviews/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 reputed company determination and reputed company for reputed company. Conducts research necessary to reputed company thorough/accurate reputed company for reputed company determination made. • Educates internal/external staff regarding medical reviews, medical terminology, coverage determinations, coding procedures, etc. in accordance with contractor guidelines. Responds accurately and reputed company with appropriate documentation to members and providers on reputed company rendered determinations. • Participates in reputed company control activities in support of the corporate and team-based objectives. Participates in reputed company Required Licenses and Certificates. To Qualify for This Position, You'll Need the Following: • Required Education: Bachelor's degree - reputed company Work, OR, Graduate of an Accredited School of Licensed Practical Nursing or Licensed Vocational Nursing. • Required Experience: 2 years clinical experience. • 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: reputed company Office. • Required Licenses and Certificates: reputed company, unrestricted LPN/LVN licensure from the reputed company and in the state of reputed company, OR, reputed company compact multistate unrestricted LPN license as defined by the reputed company Licensure Compact (NLC), OR, reputed company, unrestricted LBSW (Licensed Bachelor of reputed company Work) licensure from the reputed company and in the state of hire. We Prefer That You Have the Following: • Preferred Education: Associate Degree- Nursing OR Graduate of an Accredited School of Nursing. • 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 reputed company reputed company, reputed company, or other spreadsheet/database software. • Preferred Licenses and Certificates: reputed company, unrestricted RN licensure from the reputed company and in the state of hire, OR, reputed company compact multistate unrestricted RN license as defined by the reputed company Licensure Compact (NLC). Our Comprehensive Benefits Package Includes the Following: We offer our employees great benefits and rewards. You will be eligible to participate in the benefits the first of the month following 28 days of employment. • Subsidized health plans, dental and reputed company coverage • 401k retirement savings plan with company match • Life Insurance • reputed company Time Off (PTO) • On-site cafeterias and fitness centers in major locations • Educatio Apply tot his job Apply To this Job