Reviewer I, Medical

Duties

• Performs medical reviews using established criteria sets and/or performs utilization management of professional, inpatient or outpatient, facility benefits or services, and appeals.
• Documents decisions using indicated protocol sets or clinical guidelines.
• Provides support and review of medical claims and utilization practices.
• May provide any of the following in support of medical claims review and utilization review practices:
• Performs medical claim reviews and makes a reasonable charge payment determination.
• Makes sure the process is done on time according to the rules set by the company.
• Ensures that the right kind of medical services are covered based on the rules and the need for those services.
• Uses the tools available to help make sure the decision is right.
• Checks if the right people have the right information to help with the process.
• Does research to understand what might happen to someone's health in the future and how much it might cost.
• Looks at people's health and decides if they need certain services.
• Talks to people about their health and helps them understand their options.
• Checks if the decisions made were done correctly and explain why.
• Teaches other people about how to do these kinds of reviews.
• Answers questions from members and providers in a way that shows they understand and can explain things clearly.
• Helps check if everything is done right and follows the company's goals.
• Attends all the classes and training sessions they need to do their job well.

Skills

• Working knowledge of word processing software.
• Good judgment skills.
• Demonstrated customer service and organizational skills.
• Demonstrated proficiency in spelling, punctuation, and grammar skills.
• Analytical or critical thinking skills.
• Ability to handle confidential or sensitive information with discretion.
• Ability to remain in a stationary position and operate a computer.
• Required Software and Tools: Microsoft Office.
• Preferred Skills and Abilities: Working knowledge of spreadsheet and database software.
• Demonstrated oral and written communication skills.
• Ability to persuade, negotiate, or influence others.
• Preferred Software and Others Tools: Knowledge of Microsoft Excel, Access, or other spreadsheet/database software.