Compliance Audit Professional
2 days ago
Key Responsibilities
- Review medical documents and apply clinical criteria to establish the most appropriate level of care.
- Conduct retrospective utilization reviews and first-level determination approvals for members using BSC evidenced-based guidelines, policies, and nationally recognized clinical criteria across lines of business or for a specific line of business such as Medicare and FEP.
- Prepare and present cases to Medical Directors for medical director oversight and necessity determination.
- Develop and review member-centered documentation and correspondence reflecting determinations in compliance with regulatory and accreditation standards.
The estimated salary for this position is around $83,000 - $110,000 per year, based on industry standards and location.
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