Medical Review Specialist

Responsibilities
This position reports directly to the Supervisor or Manager of Business Analysis/Provider EDI/Appeals. And is accountable for supporting multiple departments in performing functions related to Medical Review or Medical Claims processing. Completes all stages of Out Patient Medical Pre Authorizations and Claims Approval/Appeals from providers/vendors or internal sources. Uses clinical knowledge and experience to research Client and other policies. Collaborates with outside URV's to ensure quality care is provided for members. Facilitates BDCT contracts between CFA and URV. While utilizing and applying plan document language for claim benefit determination.
This position reports to the Supervisor or Manager of Business Analysis/Provider EDI/Appeals. The principle duties and responsibilities include but are not limited to the following:

• Investigation of al internal and external out patient pre authorizations.
• Analyzes Plan Document Language. Updates Plan Document Language.
• Prepares policy and procedures to direct interdepartmental communications.
• Communicates outcomes of Medical Review to appropriate departments.
• Coordinates interdepartmental responses regarding provider and member claims.
• Manages urgent Medical Reviews while complying with DOL regulations.
• Interprets claims editing and accuracy.
• Review of Medical Records or CPT/HCPC coding and verbiage.
• Medical Review account management support.
• Medical Review plan configuration support.
• Coordinates UR vendors and CFA processes and procedures.
• Medical Review UR vendor training and support.
• Assists all CFA associates with medical determination and claims completion.
• UF, CFA associate training Webinars.
• Facilitations of all paperwork for BDCT contracts between CFA, URV and facility.
• Refers first level appeals to second nurse for independent review.
• Refers second level appeals to an outside Utilization review vendor.
• Maintains Medical Review log data.

Qualifications
Required: LPN or RN or healthcare or business related field and a minimum of 3-5 years of office, hospital or Medical Review. Claims processing background, in depth summary plan document interpretation. Travel will be required in accordance with business needs.