Medical Reviewer I

Spectraforce Technologies, Inc.; Columbia (SC); Remote; USD 42,000 - 59,000; Full time

Job summary

Spectraforce Technologies, Inc. is seeking a Medical Reviewer I to perform medical reviews and utilization management in a remote-capable role based in Columbia, SC.

The position starts with onsite training and transitions to remote work after 1–2 weeks, with a Mon-Fri schedule and EST hours. Qualified candidates will have a healthcare background, licensure options (LPN/LVN or RN, or social work background), and at least two years of clinical experience.

Qualifications

• Requires Bachelor's degree in Social Work or nursing licensure.
• LPN/LVN or RN licensure with US state authorization preferred.
• Clinical experience of at least 2 years required.
• Strong documentation and communication skills essential.

Responsibilities

• Perform medical claim reviews and utilization management.
• Ensure timely processing and accurate documentation of determinations.
• Educate staff and providers on medical review processes and terminology.
• Participate in quality control and training activities.

Skills

Analytical thinking

Customer service

Attention to detail

Communication skills

Discretion with confidential info

Education

Bachelor's degree - Social Work

LPN/LVN diploma

Associate degree in Nursing

Tools

Microsoft Office

Job description

Role Name: Medical Reviewer I

Location: Columbia, SC 29229

Work Environment: Remote (after 1-2 weeks of onsite training)

Shift: Mon - Fri, 8:30am to 5pm EST

Contract length: 3 months assignment with possible extension

Summary

Performs medical reviews using established criteria sets and/or performs utilization management of professional, impatient 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.

Responsibilities

• 80% 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 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.
• 10% 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.
• 10% Participates in quality control activities in support of the corporate and team-based objectives. Participate in all required training.

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.

Preferred Skills and Abilities

• Working knowledge of spreadsheet and database software.
• Demonstrated oral and written communication skills.
• Ability to persuade, negotiate, or influence others.

Preferred Software and Other Tools: Knowledge of Microsoft Excel, Access, or other spreadsheet/database software.

Work Environment

Typical office environment some travel between office buildings.

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' clinical experience.

Required Licenses and Certificates

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.

Preferred Education

Associate degree- Nursing OR Graduate of an Accredited School of Nursing.

Preferred Licenses and Certificates

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).