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

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