Job Title: Medical Claims Reviewer Pay Rate:23/Hr (REMOTE opportunity after training) Duration:3+ Months on W2 Location:4101 Percival Road Columbia SC 29229 United States Active, unrestricted LPN/LVNlicensure from the United States and in the state of hired, OR, active compact multistate unrestricted LPN license as defined by the Nurse Licensure Compact (NLC), OR, active, unrestricted LBSW (Licensed Bachelor of Social Work) licensure from the United States and in the state of hire. Job Description: As a Medical Claims Reviewer/Utilization Management Specialist, you will be responsible for conducting medical reviews using established criteria sets, performing utilization management of professional, inpatient or outpatient, facility benefits or services, and addressing appeals. Your role will involve documenting decisions in line with clinical guidelines and protocols, ensuring compliance with medical necessity and benefit guidelines. Key Responsibilities:
- Perform medical claim reviews and make reasonable charge payment determinations.
- Monitor process timeliness to meet contractor standards.
- Authorize appropriate medical services within benefit and medical necessity guidelines.
- Utilize allocated resources to support review determinations.
- Review interdepartmental requests and medical information efficiently to complete the utilization process.
- Conduct high-dollar forecasting research and formulate overall patient health summaries with future health prognoses and projected medical costs.
- Perform screenings and assessments to determine risk via telephone.
- Review and determine eligibility, level of benefits, and medical necessity of services.
- Ensure thorough documentation of each determination for utilization or claims review.
- Review first-level appeals and provide accurate basis for determinations.
- Provide education to members, families, and caregivers about medical reviews and services.
- Educate internal and external staff on medical reviews, coverage determinations, and coding procedures.
- Provide timely and accurate responses with appropriate documentation to members and providers on determinations made.
- Participate in quality control activities aligned with corporate and team objectives.
- Engage in all required training to maintain compliance and ensure ongoing process improvement.
Qualifications:
- Strong understanding of medical claims review processes, medical necessity guidelines, and utilization review practices.
- Proficiency in medical terminology, coding procedures, and healthcare benefits.
- Excellent communication skills, both written and verbal, with the ability to provide clear and accurate documentation.
- Experience in working with various healthcare and insurance systems to support decision-making.
- Ability to collaborate across departments and provide educational support to both internal and external stakeholders.
- Strong analytical skills to assess medical information, conduct research, and make accurate determinations.
- Familiarity with contractor standards, healthcare compliance, and claims authorization processes.
If this is a role that interests you and you'd like to learn more, click apply now and a recruiter will be in touch with you to discuss this great opportunity. We look forward to speaking with you!About ManpowerGroup, Parent Company of:Manpower, Experis, Talent Solutions, and Jefferson Wells ManpowerGroup® (NYSE: MAN), the leading global workforce solutions company, helps organizations transform in a fast-changing world of work by sourcing, assessing, developing, and managing the talent that enables them to win. We develop innovative solutions for hundreds of thousands of organizations every year, providing them with skilled talent while finding meaningful, sustainable employment for millions of people across a wide range of industries and skills. Our expert family of brands - Manpower, Experis, Talent Solutions, and Jefferson Wells - creates substantial value for candidates and clients across more than 75 countries and territories and has done so for over 70 years. We are recognized consistently for our diversity - as a best place to work for Women, Inclusion, Equality and Disability and in 2022 ManpowerGroup was named one of the World's Most Ethical Companies for the 13th year - all confirming our position as the brand of choice for in-demand talent.