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E-Verify Program

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Medical Review Analyst

AnalystAnalystOtherRemoteSeniorTeam 501-1,000Since 1997H1B No SponsorCompany SiteLinkedIn

Location

North Carolina

Posted

120 days ago

Salary

$73.7K - $117.9K / year

Seniority

Senior

Associate Degree3 yrs expEnglish

Job Description

Medical Review Analyst

E-Verify Program

• Identifies, analyzes, and determines medical necessity, pre-existing conditions, benefit eligibility and/or individual consideration reimbursement allowances for novel and complex medical management related claims • Acts as a member advocate to promote and coordinate the delivery of quality, cost-effective healthcare services based on medical necessity and contractual benefits • Ensures that review and determinations meet all requirements per line of business by Regulatory and Accrediting bodies • Identifies, documents, and escalates system and process problems • Through analysis, determines root cause and recommends possible solutions • Reviews physician-submitted and member-submitted claims for specified services, utilizing professional knowledge and developed criteria • Refers cases that do not meet criteria to the Medical Director with appropriate clinical analysis and summaries • Issues denials according to department protocols • Documents outcome of reviews • Maintains confidentiality of all PHI in compliance with state and federal laws • Recognizes, documents, and reports inappropriate billing patterns or utilization trends of professional and institutional providers to appropriate business owner • Identifies situations in which claims filing/coding guidelines are not being followed by providers • Communicates with members and providers to obtain additional information • Informs members, providers, and internal customers of claims status and determinations • Performs post adjudication review of claims related to coding, billing and reimbursement

Job Requirements

  • RN with a minimum of 3 years previous clinical experience preferably in a variety of clinical settings
  • LPN with a minimum of 5 years previous clinical nursing experience preferably in a variety of clinical settings
  • Must hold and maintain a valid North Carolina clinical license

Benefits

  • The opportunity to work at the cutting edge of health care delivery with a team that’s deeply invested in the community
  • Work-life balance, flexibility, and the autonomy to do great work
  • Medical, dental, and vision coverage along with numerous health and wellness programs
  • Parental leave and support plus adoption and surrogacy assistance
  • Career development programs and tuition reimbursement for continued education
  • 401k match including an annual company contribution

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