Job Summary:
The Medical Reviewer is responsible for ensuring accurate, timely, and contract-compliant review of clinical cases. This role supports quality improvement initiatives, serves as a resource for clinical and provider inquiries, and contributes to maintaining high standards in utilization review and prior authorization processes.
Responsibilities:
- Assures accuracy and timeliness of all applicable review type cases within contract requirements
- Assesses, evaluates, and addresses daily workload and queues; adjusts work schedules daily to meet the workload demands of the department
- In collaboration with Supervisor, responsible for the quality monitoring activities including identifying areas of improvement and plan implementation of improvement areas
- Maintains current knowledge base related to review processes and clinical practices related to the review processes, functions as the initial resource to nurse reviewers regarding all review process questions and/or concerns
- Functions as providers’ liaison and contact/resource person for provider customer service issues and problem resolution
- Performs all applicable review types as workload indicates
- Fosters positive and professional relationships and act as liaison with internal and external customers to ensure effective working relationships and team building to facilitate the review process
- Attends training and scheduled meetings and for maintenance and use of current/updated information for review
- Cross trains and perform duties of other contracts to provide a flexible workforce to meet client/customer needs
- Read, understand, and adhere to all corporate policies including policies related to HIPAA and its Privacy and Security Rule
Job Requirements and Qualifications
Required qualifications:
- Licensed Practical Nurse (LPN) license or Registered Nurse (RN) license for the State of Virginia or compact license (will be required to obtain Virginia license within a year)
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- For LPN – Associate’s degree or Practical nursing diploma or practical nursing certificate program, in accordance with state requirements
- For RN – Bachelor’s Degree from an accredited college or university in a related field
- 2+ year of experience in Prior Authorization, Utilization Review, or Utilization Management
Preferred qualifications:
- Able to work alternating weekends
- Knowledge of the organization of medical records, medical terminology, and disease process
- Strong clinical assessment and critical thinking skills
- Requires excellent written and verbal communication skills
- Medical record abstracting skills
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