Perform medical claim reviews to determine medical necessity, appropriateness, and coverage based on established clinical guidelines. Document rationale for payment or denial decisions and provide education to staff regarding medical terminology and coding procedures.
The Senior Medical Reviewer acts as a team lead for specialty programs, providing guidance, training, and direction to staff while ensuring appropriate healthcare service levels. They monitor workflows, participate in quality reviews, and resolve discrepancies by collaborating with internal departments and external entities.
The auditor conducts financial, compliance, and operational audits to evaluate internal controls and identify business risks. They also draft reports for executive management with recommendations to improve processes and ensure data integrity.
The consultant educates medical providers on Medicare coverage, documentation, and utilization statistics through written advisories and formal workshops. They also analyze provider billing practices and coordinate with the medical review department to address over-utilization and compliance issues.
The consultant educates medical providers on Medicare coverage, utilization statistics, and documentation requirements through various communication channels. They also conduct workshops and analyze reports to identify and address provider billing practices and over-utilization of services.
Develop and produce educational materials for network providers, physicians, and staff while facilitating training sessions and workshops. Act as a liaison between the organization and various healthcare stakeholders to resolve issues and ensure educational needs are met.
Conducts internal and external financial, operational, and compliance audits to evaluate internal controls and business risks. Prepares detailed audit reports for executive management with recommendations to improve processes and ensure data integrity.
The Case Management Coordinator provides active care management, assesses service needs, and develops action plans to improve care coordination and member outcomes. They also evaluate medical necessity, ensure accurate clinical documentation, and provide telephonic support and coaching to members with chronic or high-risk conditions.
The RN Behavioral Health Concierge Care Manager provides high-touch case management for members with complex conditions to facilitate care coordination and gap closure. They are responsible for implementing program goals, managing treatment plans, and educating members on medications and care adherence.
The Managed Care Coordinator evaluates medical necessity and clinical criteria to authorize services and ensure care plan compliance. They also provide patient education and coordinate with providers to promote quality, cost-effective health outcomes.
The Medical Director analyzes medical review utilization data and develops claim adjudication criteria for medical and regulatory matters. They also act as a lead resource for providers and internal staff while conducting research on new medical procedures and technology.
The Molecular Diagnostics Medicare Medical Director oversees medical staff, analyzes utilization data, and researches emerging molecular technologies to support Medicare coverage decisions. They also develop medical policies and serve as a liaison between the company and the medical community.
Under general supervision, the Accounting Technician III performs a variety of routine to complex clerical and accounting functions. Responsibilities include inventory balancing, reconciliations, processing disbursements and deposits, and generating refund request letters.
