Medical Reviewer II (Prior-Auth A/B MAC)

About the position

Responsibilities

Perform medical claim reviews for complex services, preauthorization requests, appeals, and potential fraud cases.
Make payment determinations based on clinical information and established criteria.
Determine medical necessity and appropriateness for coverage and reimbursement.
Monitor process timeliness according to contractor standards.
Document medical rationale for payment or denial of services.
Educate internal and external staff on medical reviews, terminology, and coding procedures.
Participate in quality control activities and provide guidance to LPN team members.
Assist with special projects and responsibilities as assigned by management.

Requirements

Active, unrestricted RN licensure from the United States or a compact multistate unrestricted RN license.
Associate degree 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 and prioritize effectively.
Good judgment and demonstrated customer service skills.
Strong oral and written communication skills.
Analytical or critical thinking skills.
Ability to handle confidential information with discretion.
Proficiency in Microsoft Office.

Nice-to-haves

Five years of clinical experience as a Registered Nurse, including two years in 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 skills in Word, Excel, and Outlook.

Benefits

Medical Reviewer II (Prior-Auth A/B MAC) - CGS