Medical Reviewer I

4 weeks ago

Columbia, United States LanceSoft Full time

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.
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'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.
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. Participates 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 Others Tools:

Knowledge of Microsoft Excel, Access, or other spreadsheet/database software.

Work Environment:

Typical office environment some travel between office buildings.

  • Medical Reviewer I

    1 week ago

    Columbia, United States Spectraforce Technologies Full time

    Job Title: Medical Reviewer I Location: Columbia, SC , 29229 (2 weeks onsite training then remote) Duration: 12 months assignment with possible extension Shift: M - F, 8:30 am - 5 pm Pay Rate: $23/hrSummary: Performs medical reviews using established criteria sets and/or performs utilization management of professional, inpatient or outpatient, facility...

  • Medical Reviewer I

    2 days ago

    Columbia, United States Spectraforce Technologies Full time

    Job Title: Medical Reviewer I Location: Columbia, SC , 29229 (2 weeks onsite training then remote) Duration: 12 months assignment with possible extension Shift: M - F, 8:30 am - 5 pm Pay Rate: $23/hrSummary: Performs medical reviews using established criteria sets and/or performs utilization management of professional, inpatient or outpatient, facility...

  • Reviewer I, Medical

    2 weeks ago

    Columbia, United States Ask Staffing Full time

    "All candidates must be directly contracted by ASK Consulting on their payroll and cannot be subcontracted. We are unable to provide sponsorship at this moment".Job Title: Medical Reviewer ILocation: Columbia, SC- 29229Duration: 12 months contract pay scale is $20-$23/hr Job Description:Note: Please share this job posting within 40miles of Columbia, SC-...

  • Reviewer I, Medical

    2 weeks ago

    Columbia, United States LanceSoft Full time

    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. May provide any of the...

  • Reviewer I, Medical

    5 days ago

    Columbia, United States LanceSoft Full time

    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. May provide any of the...

  • Reviewer I, Medical

    14 hours ago

    Columbia, United States LanceSoft Full time

    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. May provide any of the...

  • Reviewer I, Medical

    2 weeks ago

    Columbia, United States Mindlance Full time

    Duties: 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. 80% May provide any of...

  • LPN Medical Reviewer

    5 days ago

    Columbia, United States SPECTRAFORCE Full time

    Job Title: Medical Reviewer ILocation: Columbia, SC, 29229 (3 to 4 week onsite training then remote)Duration: 7 months assignment with possible extensionsShift: M - F, 8:30 am - 5 pmPay Rate: $24/hrIn this role, you'll review medical records, ensure accurate coverage decisions based on medical necessity, and sometimes interact with providers and...

  • Medical Reviewer II

    1 day ago

    Columbia, United States BlueCross BlueShield of South Carolina Full time

    Description   Logistics This position is full time (40 hours/week) Monday-Friday and will be located at 4101 Percival Road, Columbia, S.C., 29229. What You Will Do: Performs medical claim reviews for one or more of the following: claims for medically complex services, services that require preauthorization/predetermination, requests for...

  • Scientist I, Data Review

    7 days ago

    Columbia, United States Eurofins Full time

    Job Description Responsibilities include reviewing work for research and development under CGMP and/or GLP guidelines for studies, documentation, etc. Assisting in reviewing, monitoring and reporting studies to ensure data accuracy and report quality. Providing somewhat complex analytical review work on projects and studies using a knowledge of...

  • Scientist I, Data Review

    2 days ago

    Columbia, United States Eurofins Full time

    Job Description Responsibilities include reviewing work for research and development under CGMP and/or GLP guidelines for studies, documentation, etc. Assisting in reviewing, monitoring and reporting studies to ensure data accuracy and report quality. Providing somewhat complex analytical review work on projects and studies using a knowledge of...

  • Scientist I, Data Review

    5 days ago

    Columbia, United States Eurofins BioPharma Product Testing Columbia, Inc. Full time

    Company DescriptionEurofins Scientific is an international life sciences company which provides a unique range of analytical testing services to clients across multiple industries. The Group believes it is the world leader in food, environment and pharmaceutical products testing and in agroscience CRO services. It is also one of the global independent market...

  • Scientist I, Data Review

    4 days ago

    Columbia, South Carolina, United States Eurofins BioPharma Product Testing Columbia, Inc. Full time

    Company DescriptionEurofins Scientific is an international life sciences company which provides a unique range of analytical testing services to clients across multiple industries. The Group believes it is the world leader in food, environment and pharmaceutical products testing and in agroscience CRO services. It is also one of the global independent market...

  • Scientist I, Data Review

    16 hours ago

    Columbia, United States Eurofins BioPharma Product Testing Columbia, Inc. Full time

    Company DescriptionEurofins Scientific is an international life sciences company which provides a unique range of analytical testing services to clients across multiple industries. The Group believes it is the world leader in food, environment and pharmaceutical products testing and in agroscience CRO services. It is also one of the global independent market...

  • Scientist I, Data Review

    2 days ago

    Columbia, South Carolina, United States Eurofins BioPharma Product Testing Columbia, Inc. Full time

    Company DescriptionEurofins Scientific is an international life sciences company which provides a unique range of analytical testing services to clients across multiple industries. The Group believes it is the world leader in food, environment and pharmaceutical products testing and in agroscience CRO services. It is also one of the global independent market...

  • Utilization Review Specialist

    4 days ago

    West Columbia, United States Lexington Medical Center Full time

    Utilization Management Dept. Full Time AM Shift 7:30-4:00 Consistently named best hospital, Lexington Medical Center dedicates itself to providing quality health services that meet the needs of its communities. Ranked #2 in the state and #1 in the Columbia metro area by U.S. News & World Report, Lexington Medical Center is the only hospital named one of...

  • Utilization Review Specialist

    2 days ago

    West Columbia, United States Lexington Medical Center Full time

    Utilization Management Dept. Full Time AM Shift 0700-1530 Consistently named best hospital, Lexington Medical Center dedicates itself to providing quality health services that meet the needs of its communities. Ranked #2 in the state and #1 in the Columbia metro area by U.S. News & World Report, Lexington Medical Center is the only hospital named one of...

  • Review Assistant

    3 weeks ago

    Columbia, United States Absolute Staffing & Consulting Solutions Full time

    Job DescriptionJob DescriptionOn behalf of our client, we are looking for a Review Assistant to join our team of professionals. If the description below sounds like you, Apply Now!*Candidates must live within driving distance of Columbia, MD and have a background in administrative healthcare*As a Review Assistant, you will be responsible for inbound and...

  • Review Assistant

    2 days ago

    Columbia, United States Absolute Staffing & Consulting Solutions Full time

    Job DescriptionJob DescriptionOn behalf of our client, we are looking for a Review Assistant to join our team of professionals. If the description below sounds like you, Apply Now!*Candidates must live within driving distance of Columbia, MD and have a background in administrative healthcare*As a Review Assistant, you will be responsible for inbound and...

  • Utilization Review Specialist

    4 weeks ago

    Columbia, United States Acadia Healthcare Inc. Full time

    * SIGN-ON BONUS: $5,000 - if Licensed Registered Nurse (RN) ESSENTIAL FUNCTIONS: * Act as liaison between managed care organizations and the facility professional clinical staff. * Conduct reviews, in accordance with certification requirements, of insurance plans or other managed care organizations (MCOs) and coordinate the flow of communication concerning...