Performs medical claim reviews for one or more of the following: claims for medically complex services, services that require preauthorization/predetermination, requests for appeal or reconsideration, referrals for potential fraud and/or abuse, correct coding for claims/operations.
Makes reasonable charge payment determinations based on clinical/medical information and established criteria/protocol sets or clinical guidelines.
Determines medical necessity, appropriateness, and/or reasonableness and necessity for coverage and reimbursement.
Monitors process’s timeliness in accordance with contractor standards.
Documents medical rationale to justify payment or denial of services and/or supplies.
Educates internal and external staff regarding medical reviews, medical terminology, coverage determinations, coding procedures, etc., in accordance with contractor guidelines.
Participates in quality control activities in support of the corporate and team-based objectives.
Provides guidance, direction, and input as needed to LPN team members.
Provides education to non-medical staff through discussions, team meetings, classroom participation, and feedback.
Assists with special projects and specialty duties/responsibilities as assigned by management.

Active RN licensure in state hired, OR, active compact multistate RN license as defined by the Nurse Licensure Compact (NLC)
Associate in a job-related field OR graduate of an Accredited School of Nursing
Two years of clinical nursing experience
Working knowledge of word processing software
Ability to work independently, prioritize effectively, and make sound decisions
Good judgment skills
Demonstrated customer service and organizational skills
Demonstrated oral and written communication skills
Analytical or critical thinking skills
Ability to handle confidential or sensitive information with discretion
Five years of clinical experience as a Registered Nurse, including two years in specialty area(s): Outpatient Surgical, Pain Management, Cosmetic Surgery, Prior Authorization, Medical Review, Medicare Part A, or Utilization Management.
Ability to work with multiple Windows-based programs simultaneously.
Intermediate Word, Excel, and Outlook skills.

Medical Reviewer II – Prior-Auth A/B MAC

Key skills