Case Reviewer

About the role

As a Case Reviewer, you will perform utilization reviews to authorize services for individuals enrolled in Medicaid. The utilization review process involves applying program policies, verifying medical, technical, and financial eligibility, and reviewing medical records to issue decisions regarding pre-authorization of services.

Training will be on-site at our Columbia, MD, office and take approximately 3-6 weeks, Monday through Friday, 9am to 5pm. Once training has concluded, you will be required to come to the office for quarterly in-person training or team events.

Responsibilities

• Provides review decisions for prospective reviews based on an established set of criteria.
• Screens situations according to specific criteria to determine if care is appropriate.
• Refers cases that fail to meet criteria to a Registered Nurse or Social Worker reviewer.
• Ensures review is conducted thoroughly and within specified timeframes.
• Serves as liaison among clinical reviewer, provider, facility, and/or subscriber.
• Documents medical information supporting decisions into the workflow documentation system, ensuring data is entered accurately and timely.
• Ensures quality customer service by responding to email and phone inquiries from providers and consumers.

Requirements

• Bachelor’s degree in health or human services and at least 1 year of experience in utilization review or 1 year of experience evaluating, analyzing, researching, and developing health care services, policies, and programs preferred OR a high school diploma or equivalent may substitute for a bachelor’s degree with at least three years of experience in utilization review or three years of experience evaluating, analyzing, researching, and developing health care services, policies, and programs.
• Demonstrated ability working with confidential information and in a deadline-driven environment.
• Excellent verbal and written communication skills.
• Comfortable with completing basic math functions.
• Attention to detail, analytical skills, and the ability to interpret medical documentation accurately.
• Possess intermediate PC skills including navigating electronic health records and other computer software.
• Ability to work independently and as part of a team.
• Organizational skills and time management.

Preferred Qualifications

• Experience in a community health care environment.
• Experience with utilization review of medical services.
• Satisfactory completion of a medical terminology course.
• Proficiency with SharePoint.
• Intermediate Excel skills.
• Strong analytical and critical thinking skills.