Medical Review 3

Day to Day Responsibilities
• Review and process appeals resulting from member-generated pre-service or post-service concerns or complaints.
• Report directly to the Nurse Manager.
• Review all medical records and documentation concurrently while processing member-generated appeals.
• Perform accurate and timely first-level reviews according to company and regulatory standards.
• Utilize National Coverage Determination (NCD) guidelines, Local Coverage Determination (LCD) guidelines, Milliman Care guidelines, and other nationally recognized sources such as NCCN and ACOG.
• Review appeals for benefits, medical necessity, coding accuracy, and medical policy compliance.
• Collaborate with medical directors, coordinators, and leadership to review, process, and provide a final determination for all clinical appeals with clear rationales and any necessary follow-up actions.

Required Skills (top 3 non-negotiables):
• Managed Care Experience (MCG, LCD, and NCD knowledge) – 2 years minimum
• Acute or Sub-Acute Clinical Experience – 2 years minimum
• Knowledge of Commercial and Medicare Health Coverage Benefits and Reviews
• Previous experience with prior authorization, pre-service, and post-service review

Preferred Skills (nice To Have)
• Strong Understanding of Regulatory Requirements pertaining to Health Insurance (NCQA, CMS, DMHC, DHCS)
• Strong Skills with Excel, Microsoft, PDF, Shared drive, medical records review
• Ability to work in a fast-paced and changing environment
• Strong communication skills
• Ability to work independently and in a team setting
• Strong clinical assessment skills and ability to recognize discrepancies or inaccuracies in medical determinations/clinical documentation

Apply Job!