Summary
 

Performs medical reviews using established criteria sets and/or performs utilization management of professional, inpatient or outpatient, facility benefits or services, and appeals. Documents decisions using indicated protocol sets or clinical guidelines. Provides support and review of medical claims and utilization practices.

Description
 

Location

This position is full-time (40 hours/week) Monday-Friday from 8:00 am - 4:30 pm ET, and will work from home after 6 months of on-site training and once production goals and quality checks are met.

• Due to TRICARE security access requirements for this position, the selected candidate must be a U.S. citizen, complete a Department of Defense SF85 or SF86 form via the electronic system eAPP, Declaration for Federal Employment Form OF 306 and submit two fingerprint cards. The U.S. government will be completing a thorough background investigation on the candidate selected for this position.

What You Will Do:

• May provide 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 within benefit and medical necessity guidelines. Utilizes allocated resources to back up review determination. Reviews interdepartmental requests and medical information in a timely/effective manner in order to complete utilization process. May conduct/perform high dollar forecasting research and formulate overall patient health summaries with future health prognosis and projected medical costs. Performs screenings/assessments and determines risk via 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 each determination and basis for each. Conducts research necessary to make thorough/accurate basis for each determination made.
• Educates internal/external staff regarding medical reviews, medical terminology, coverage determinations, coding procedures, etc. in accordance with contractor guidelines. Responds accurately and timely with appropriate documentation to members and providers on all rendered determinations.
• Participates in quality control activities in support of the corporate and team-based objectives. Participates in all Required Licenses and Certificates.

To Qualify for This Position, You Will Need:

• Required Education: Bachelor's degree - Social Work, OR, Graduate of an Accredited School of Licensed Practical Nursing or Licensed Vocational Nursing.
• Required Experience: 2 years of 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: Microsoft Office.
• Required