Medical Review Specialist

4 days ago


Bellevue, Washington, United States Dane Street, LLC Full time
Job Summary

Dane Street, LLC is seeking a highly skilled Medical Review Specialist to join our team. As a Clinical Reviewer, you will utilize your expertise to review insurance appeals, prospective and retrospective claims, and provide an interpretation of the medical necessity of services provided by other healthcare professionals.

Key Responsibilities
  • Medical Record Review: Review all medical records and address each question posed by the client utilizing client-specific criteria or other nationally recognized evidence-based criteria.
  • Rationale Development: Ensure that the rationale for the determination is clear, concise, and contains adequate supporting documentation to substantiate the decision.
  • Criteria Utilization: Identify, critique, and utilize current criteria and resources such as national, state, and professional association guidelines and peer-reviewed literature that support sound and objective decision-making and rationales in reviews.
  • Case Management: Return cases on or before the due date and time, and provide copies of any criteria utilized in a review with the report in a timely manner.
  • Communication: Make telephone calls as mandated by the state and/or client specifics, and maintain proper credentialing and state licenses and any special certifications or requirements necessary to perform the job.
  • Quality Assurance: Identify and respond to quality assurance issues, complaints, regulatory issues, depositions, court appearances, or audits.

Requirements: A WA license and certification, or willingness to become certified, with the Washington State Department of Labor and Industries (L&I), and the ability to work independently as a 1099 independent contractor.


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