Medical Review Analyst

4 days ago

Remote, Oregon, United States Verve LLC Full time $40,000 - $60,000 per year

Job Summary

The Medical Review Analyst is responsible for analyzing medical data, reports, and case documentation to ensure compliance with regulatory standards and organizational policies. This role supports the medical review process by developing, maintaining, and reporting on medical review activities, identifying trends, and implementing corrective actions to improve program effectiveness. The analyst also serves as a liaison during audit activities and collaborates with internal and external partners to enhance process efficiency and accuracy.

Responsibilities

  • Conduct analysis of medical review data and reports to assess program performance and identify areas for improvement.
  • Serve as a liaison during audit and compliance review activities.
  • Apply Progressive Corrective Action (PCA) principles in accordance with applicable regulations and Statements of Work (SOW).
  • Evaluate analytics to identify high-risk services, providers, or billing patterns.
  • Recommend and implement corrective actions to reduce provider error rates.
  • Manage medical review case activities, including updates, documentation, and reporting.
  • Develop and maintain statistical reports to assess edit effectiveness and review outcomes.
  • Coordinate meetings with case managers, data analysts, and other stakeholders.
  • Prepare and submit System Action Memos (SAMs) and other required documentation.
  • Provide training and support to medical review staff on case management procedures.
  • Collaborate with internal teams, data analysts, medical directors, and external partners to ensure accurate and efficient reviews.
  • Assist Provider Outreach and Education (POE) efforts with relevant data and insights.
  • Support internal and external audit activities as needed.
  • Contribute to a positive, team-oriented, and adaptable work environment.
  • Perform other duties as assigned by management.
  • Train and mentor new staff members.
  • Review updates from CMS or other governing bodies and ensure necessary changes are implemented in processes and documentation.

Qualifications

  • Experience in medical review and case management activities.

Experience with data analysis, reporting tools, and system edit evaluation.

Associate degree in Business, Medical Administration, Case Management, or related field, or equivalent combination of education and relevant experience.

  • At least two (2) years of experience in Medicare, medical review, or related case management activities.
  • Strong analytical and data interpretation skills.
  • Proficiency with Microsoft Office Suite (Excel, Word, PowerPoint, Outlook).
  • Excellent verbal and written communication skills.
  • Working knowledge of medical review processes, claims systems, and edit development.

Job Type: Full-time

Pay: $ $24.00 per hour

Benefits:

  • 401(k)
  • 401(k) matching
  • Dental insurance
  • Disability insurance
  • Employee assistance program
  • Health insurance
  • Health savings account
  • Life insurance
  • Vision insurance

Work Location: Remote

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