Reviewer I, Medical

1 week ago

Columbia South Carolina, Richland County, SC, United States Experis Full time

Our client, the healthcare service providers industry, is seeking a Reviewer I, Medical, to join their team. This role is suited for professionals with clinical experience and a background in medical claims review, seeking an opportunity to make an impact through utilization management and patient support.

Job Title: Medical Claims and Utilization Review Specialist

Location: Columbia , SC (Remote after 2 weeks training.)

Pay Range: $23/hr on w2

What’s the Job?

The Medical Claims and Utilization Review Specialist is responsible for conducting medical reviews using established criteria sets as well as managing utilization reviews for professional, inpatient, outpatient, and facility services. This position documents decisions following clinical guidelines and provides support in reviewing medical claims and utilization practices.

Key Responsibilities:

  • Medical Claims Review (80%):

    • Perform medical claim reviews and determine reasonable charge payments.
    • Monitor processing timeliness in accordance with contractor standards.
    • Ensure coverage for appropriate medical services based on benefit and medical necessity guidelines.
    • Support the authorization process and review interdepartmental requests and medical information to complete the utilization process.
    • Conduct high-dollar forecasting research and prepare patient health summaries with future medical cost projections.
    • Perform screenings and assessments via telephone to determine risk and eligibility.
    • Review eligibility, benefits level, and medical necessity of services.
    • Provide education to members, their families, and caregivers on health services.
    • Review and document first-level appeals, ensuring thorough documentation and accurate determinations.

  • Education and Communication (10%):

    • Educate internal and external staff on medical reviews, terminology, coverage determinations, and coding procedures according to contractor guidelines.
    • Respond timely and accurately to members and providers with appropriate documentation of determinations.

  • Quality Control (10%):

    • Participate in quality control activities and team-based objectives.
    • Attend and participate in all required training.

Required Skills and Abilities:

  • Proficient in Microsoft Office (Word, Excel).
  • Strong customer service and organizational skills.
  • Excellent spelling, punctuation, grammar, and written communication skills.
  • Critical thinking, analytical, and good judgment skills.
  • Ability to handle confidential information with discretion.
  • Ability to remain in a stationary position and operate a computer for extended periods.

Preferred Skills and Abilities:

  • Working knowledge of spreadsheet and database software (e.g., Excel, Access).
  • Oral and written communication skills.
  • Ability to persuade, negotiate, or influence others.

Work Environment:

  • Typical office environment with some travel between office buildings as needed.

Education and licensure:

  • Required Education:
    • Bachelor’s degree in Social Work, OR graduation from an Accredited School of Licensed Practical Nursing (LPN) or Licensed Vocational Nursing (LVN).
    • Licensure: Active, unrestricted LPN/LVN licensure or Licensed Bachelor of Social Work (LBSW) in the state of hire, or active multistate LPN license as defined by the Nurse Licensure Compact (NLC).
  • Preferred Education:
    • Associate Degree in Nursing OR Graduate from an Accredited School of Nursing.
    • Preferred Licensure: Active, unrestricted RN license or compact multistate RN license as defined by the NLC.

If this is a role that interests you and you’d like to learn more, click apply now and a recruiter will be in touch with you to discuss this great opportunity. We look forward to speaking with you

About ManpowerGroup, Parent Company of: Manpower, Experis, Talent Solutions, and Jefferson Wells

ManpowerGroup® (NYSE: MAN), the leading global workforce solutions company, helps organizations transform in a fast-changing world of work by sourcing, assessing, developing, and managing the talent that enables them to win. We develop innovative solutions for hundreds of thousands of organizations every year, providing them with skilled talent while finding meaningful, sustainable employment for millions of people across a wide range of industries and skills. Our expert family of brands – Manpower, Experis, Talent Solutions, and Jefferson Wells – creates substantial value for candidates and clients across more than 75 countries and territories and has done so for over 70 years. We are recognized consistently for our diversity - as a best place to work for Women, Inclusion, Equality and Disability and in 2022 ManpowerGroup was named one of the World's Most Ethical Companies for the 13th year - all confirming our position as the brand of choice for in-demand talent.

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