Evaluate medical records to determine medical necessity
Perform utilization management of professional, inpatient, outpatient facility benefits or services and appeals
Document decisions using indicated protocol sets or clinical guidelines
Provide support and review of medical claims and utilization practices
Perform authorization process, ensuring coverage for appropriate medical services within benefit and medical necessity guidelines
Monitor process's timeliness in accordance with contractor standards
Conduct/perform high dollar forecasting research and formulate overall patient health summaries with future health prognosis and projected medical costs
Provide education to members and their families/caregivers
Review first level appeal and ensure thorough documentation of each determination and basis for each

Bachelor's degree
Social Work, OR, Graduate of an Accredited School of Licensed Practical Nursing or Licensed Vocational Nursing
2 years clinical experience
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
Active, unrestricted LPN/LVN licensure from the United States and in the state of hired, OR, active compact multistate unrestricted LPN license as defined by the Nurse Licensure Compact (NLC), OR, active, unrestricted LBSW (Licensed Bachelor of Social Work) licensure from the United States and in the state of hire

Medical Reviewer I

Key skills