Healthcare Medical Review Specialist

6 days ago


Kansas City, Missouri, United States WPS Health Solutions Full time

Company Overview

We are WPS Health Solutions, a leading not-for-profit health insurer and federal government contractor. Our mission is to provide high-quality healthcare services to millions of people across the US.

About the Role

We are seeking a skilled Healthcare Medical Review Specialist to join our team. As a key member of our medical review team, you will be responsible for examining medical records and claims information for first-level appeal cases to determine whether services provided were medically necessary and meet Medicare coverage guidelines.

Responsibilities

  • Clinical Review: Utilize clinical knowledge and judgment to conduct medical review of claim documentation for first-level appeal cases.
  • Clear Communication: Provide clear and concise written explanations for reason a specific claim or set of claims cannot be paid as a result of first-level redetermination.
  • Team Collaboration: Work with Redetermination Representatives to assure all redeterminations, which require a clinical decision, are responded to within CMS quality and timelines standards.
  • Analysis and Problem-Solving: Analyze appeals and identify specific high-volume problem issues and relay information to Redetermination Manager and Senior Analyst.
  • Continuous Quality Improvement (CQI): Participate in various workgroups for purposes of CQI to promote consistent medical review of claim documentation and information.

Requirements

  • Nursing Background: Associate's (ASN) or Bachelor's Degree in Nursing (BSN) and active RN license, applicable to state of practice in good standing.
  • Technical Skills: Strong computer skills with experience working in multiple online systems, including MS Outlook, Teams, OneNote, Word, and Excel.
  • Previous Experience: 1 or more years of previous experience working for another Medicare Administrative Contractor (MAC) or in Medical Management, Medical Review, Utilization Management/Review, or Appeals.

Salary Range

$66,000 to $68,000 per year, based on qualifications and experience.

Work Location

Remote work available in approved states: Arizona, Colorado, Connecticut, Florida, Georgia, Illinois, Indiana, Iowa, Michigan, Minnesota, Missouri, Nebraska, Nevada, New Jersey, North Carolina, North Dakota, Ohio, South Carolina, South Dakota, Texas, Virginia, Wisconsin.

Benefits

  • Competitive salary and benefits package
  • Performance bonus and/or merit increase opportunities
  • 401(k) with dollar-per-dollar match up to 6% of salary (100% vested immediately)
  • Competitive paid time off
  • Health insurance, dental insurance, and telehealth services start DAY 1
  • Employee Resource Groups
  • Professional and Leadership Development Programs


  • Kansas City, Missouri, United States Healthcare Support Full time

    We are seeking a Speech Language Pathologist to join our team in North Kansas City, Missouri. As a Mobile Healthcare Therapist Specialist, you will be responsible for providing high-quality patient care and support.About the Role40 hours per week, 8 hours per shift13 weeks contract durationThis is an excellent opportunity for experienced professionals to...


  • Kansas City, Missouri, United States Host Healthcare Full time

    About the PositionWe are seeking a skilled Respiratory Therapist to join our team as a Travel Healthcare Specialist in Kansas City, MO.Job SummaryThis 13-week assignment offers 36 hours of work per week with a competitive pay package. The ideal candidate will have experience in respiratory therapy and excellent communication skills.BenefitsCompetitive pay...


  • Kansas City, Missouri, United States Healthcare Support Full time

    Job OverviewWe are seeking a dedicated Travel Healthcare Specialist to join our team in North Kansas City, Missouri.Salary and BenefitsThe estimated annual salary for this position is approximately $123,676, based on 40 hours per week at $48.82 to $49.82 an hour. In addition to competitive pay, we offer a range of benefits, including:Health InsuranceDental...


  • Kansas City, Missouri, United States Healthcare Support Full time

    Job Title: Occupational Therapist - Healthcare Specialist">About the Job:">We are seeking a highly skilled Occupational Therapist to join our team in North Kansas City, Missouri. As an Occupational Therapist with Healthcare Support, you will play a critical role in helping patients regain independence and overcome physical challenges.">Salary and...


  • Kansas City, Missouri, United States Saint Joseph Medical Center Full time

    We are seeking a skilled Account Resolution Specialist to join our Business Office team at Saint Joseph Medical Center.Overview:Saint Joseph Medical Center is a premier healthcare provider with a rich tradition of delivering high-quality, compassionate care. As a member of Prime Healthcare, we are committed to our core values of quality, compassion, and...


  • Kansas City, Missouri, United States Pharmavise Corporation Full time

    OverviewWe partner with Pharmaceutical, Medical Device and Biotechnology clients to provide regulatory compliance solutions.Job SummaryA Healthcare Specialist is needed to work with our client in a dynamic environment. As a Nurse Practitioner, you will be responsible for performing independent assessments, diagnosing and treating illnesses, and managing...


  • Kansas City, Missouri, United States Host Healthcare Full time

    Job SummaryWe are seeking a skilled Occupational Therapist to join our team as a healthcare specialist in North Kansas City, MO. As a travel occupational therapist, you will provide high-quality care to patients and work closely with our experienced team of healthcare professionals.About the RoleThis is a 13-week assignment with a 40-hour workweek, working 8...


  • Kansas City, Missouri, United States HealthTrust Workforce Solutions Full time

    Overview:">We are a healthcare staffing agency dedicated to providing exceptional nursing professionals with rewarding assignments and career opportunities.">Salary: $114,564 per year">Job Description: This is a 13-week nursing assignment in an acute care hospital setting. As a Medical Care Specialist, you will be responsible for delivering high-quality...


  • Kansas City, Missouri, United States Prime Healthcare Full time

    At Prime Healthcare, we prioritize quality and compassion in our healthcare services. As a leader in medical care, we seek dedicated professionals to join our team.With a rich history dating back to 1874, St. Joseph Medical Center is a renowned institution that continues to deliver exceptional care. Our Catholic heritage and commitment to the community drive...


  • Kansas City, Missouri, United States Saratoga Medical Center Full time

    Job SummaryWe are seeking a highly skilled Medical Health Specialist to join our team at Saratoga Medical Center in Kansas City, Kansas.Salary Range:$125,000 - $150,000 per yearAbout the RoleThis is an exceptional opportunity for a Nurse Practitioner to work with patients and provide high-quality healthcare services in a fast-paced environment. The ideal...


  • Kansas City, Missouri, United States OneStaff Medical Full time

    About the RoleWe are seeking a highly skilled Medical Imaging Specialist to join our team for a 13-week assignment in Kansas City, Missouri.Job SummaryThe successful candidate will be responsible for performing imaging procedures using computed tomography (CT) scanners, ensuring high-quality images and providing excellent patient care.Key...


  • Kansas City, Missouri, United States ADEX Healthcare Staffing LLC Full time

    About the Role:ADEX Healthcare Staffing LLC is currently seeking a skilled Medical Specialist in Respiratory Care to join their team on a travel assignment in Kansas City, Missouri. As a leading healthcare staffing agency, ADEX has been placing professionals across the US since 2004.Key Details:• Specialty: Respiratory Therapist• Discipline: Allied...


  • Kansas City, Missouri, United States Research Medical Center Full time

    Quality and Safety Role OverviewWe are seeking a dedicated Registered Nurse to fill the position of Behavioral Health Quality Specialist RN at Research Medical Center. This role is an exciting opportunity for a nurse to contribute to the improvement of patient care and outcomes in our behavioral health department.About UsResearch Medical Center is a leading...


  • Kansas City, Missouri, United States Truman Medical Centers Full time

    The role of Medical Communications Specialist at Truman Medical Centers is a part-time position with varied shifts. The specialist facilitates communication between clinical/non-clinical personnel and Limited English Proficient patients/patients' families, ensuring culturally responsive and equitable care.High school diploma or equivalentSix months...


  • Kansas City, Missouri, United States Go Healthcare Full time

    Seeking a Mobility Healthcare Specialist for an opportunity in the vibrant city of Kansas City, Missouri. Go Healthcare is dedicated to delivering exceptional care to patients while fostering a supportive environment for our professionals.We offer a competitive pay package with an estimated $120 per hour based on 8-hour shifts and 40 hours per week, along...


  • Kansas City, Missouri, United States Host Healthcare Full time

    Host Healthcare is seeking a highly skilled Occupational Therapist Specialist to join our team for a 13-week assignment in North Kansas City, Missouri. This role offers the opportunity to make a meaningful difference in the lives of patients and communities.About the RoleThis Occupational Therapist position is designed to provide high-quality care to...


  • Kansas City, Missouri, United States Aya Healthcare Full time

    Aya Healthcare is hiring a skilled Medical Device Specialist to work in Kansas City, MO. This 13-week assignment offers an excellent opportunity for professionals seeking a new challenge.Salary and BenefitsThe estimated salary for this position is $43,420 - $55,350 per month, based on a 5-day, 8-hour shift schedule with overtime pay available. As a Medical...


  • Kansas City, Missouri, United States PRN Healthcare Full time

    PRN Healthcare is seeking a skilled Diagnostic Imaging Specialist to join their team in Kansas City, Missouri. As a travel CT Technologist, you will play a vital role in providing high-quality imaging services to patients.About the JobThis 13-week contract offers an estimated salary of $120,000 per year, based on 12-hour shifts and 36 hours per week. The...


  • Kansas City, Missouri, United States Titan Medical Group Full time

    Job Title: Medical Imaging SpecialistCompany Overview: Titan Medical Group is a reputable healthcare organization seeking skilled professionals to join their team.Salary: $2955 - $3155 per week, based on experience and qualifications.Job Description: We are looking for a qualified Medical Imaging Specialist to fill a 14-week assignment in Kansas City. The...


  • Kansas City, Missouri, United States Research Medical Center Full time

    Research Medical Center, a leading healthcare provider in the Kansas City area, offers an exciting opportunity for a dedicated Registered Nurse to join our team as a Medical Transplant Specialist RN.Company OverviewOur hospital is committed to delivering high-quality patient care and provides a supportive environment for our staff to grow professionally....