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 Apply Job!