Healthcare Medical Review Specialist
6 days ago
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
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