Medical Review 3

Day to Day Responsibilities
? Review and process appeals resulting from member-generated pre-service or post-service concerns or complaints.
? Report directly to the Nurse Manager.
? Review all medical records and documentation concurrently while processing member-generated appeals.
? Perform accurate and timely first-level reviews according to company and regulatory standards.
? Utilize National Coverage Determination (NCD) guidelines, Local Coverage Determination (LCD) guidelines, Milliman Care guidelines, and other nationally recognized sources such as NCCN and ACOG.
? Review appeals for benefits, medical necessity, coding accuracy, and medical policy compliance.
? Collaborate with medical directors, coordinators, and leadership to review, process, and provide a final determination for all clinical appeals with clear rationales and any necessary follow-up actions.

Required Skills (top 3 non-negotiables):
? Managed Care Experience (MCG, LCD, and NCD knowledge) ? 2 years minimum
? Acute or Sub-Acute Clinical Experience ? 2 years minimum
? Knowledge of Commercial and Medicare Health Coverage Benefits and Reviews
? Previous experience with prior authorization, pre-service, and post-service review

Preferred Skills (nice To Have)
? Strong Understanding of Regulatory Requirements pertaining to Health Insurance (NCQA, CMS, DMHC, DHCS)
? Strong Skills with Excel, Microsoft, PDF, Shared drive, medical records review
? Ability to work in a fast-paced and changing environment
? Strong communication skills
? Ability to work independently and in a team setting
? Strong clinical assessment skills and ability to recognize discrepancies or inaccuracies in medical determinations/clinical documentation

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