Performs medical reviews using clinical/medical information provided by physicians/providers and established criteria/protocol sets or clinical guidelines
Documents decisions using indicated protocol sets or clinical guidelines
Provides support and review of medical claims and utilization practices
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, and 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 and appropriateness and/or reasonableness and necessity for coverage and reimbursement
Documents medical rationale to justify payment or denial of services and/or supplies
Educates internal/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

Associate Degree Nursing, OR Four year degree in health-related field, OR Graduate of accredited School of Nursing
Two years clinical experience plus two years utilization/medical review, quality assurance, or home health experience
Working knowledge of managed care and various forms of health care delivery systems
strong clinical experience to include home health, rehabilitation, and/or broad medical surgical experience
Knowledge of specific criteria/protocol sets and the use of the same
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
Ability to persuade, negotiate, or influence others
Analytical or critical thinking skills
Ability to handle confidential or sensitive information with discretion.
Active, unrestricted RN licensure from the United States and in the state of hire, OR, active compact multistate unrestricted RN license as defined by the Nurse Licensure Compact (NLC), OR, current active, unrestricted licensure/certification from the United States and in the state of hire in specialty area as required by hiring division/area

RN Medical Reviewer III

Key skills