Senior Medical Reviewer

Pulivarthi Group LLC is a Global Staffing & IT Technology Solutions company, combining the expertise of its team with the culture of your company to provide innovative, affordable solutions using high-quality standards and technologies. We serve large healthcare, financial services, and government entities.

Job Overview/Summary

The Senior Medical Reviewer is responsible for conducting comprehensive medical reviews to ensure clinical appropriateness, regulatory compliance, and adherence to established guidelines and protocols. This role requires strong clinical expertise, particularly in behavioral health and mental illness, along with experience in managed care and utilization review processes.

Responsibilities

• Perform medical and utilization reviews in accordance with established criteria and regulatory requirements.
• Evaluate clinical documentation for medical necessity, quality of care, and compliance with healthcare guidelines.
• Apply specific criteria/protocol sets consistently and accurately.
• Collaborate with healthcare providers, case managers, and interdisciplinary teams to support appropriate care decisions.
• Review cases involving individuals with mental illnesses and behavioral health conditions.
• Ensure adherence to Medicare guidelines and managed care standards.
• Maintain accurate documentation within database and review systems.
• Work independently while effectively prioritizing workload and meeting deadlines.

Primary Skills

• Strong clinical experience including home health, rehabilitation, and/or broad medical-surgical background.
• Experience working directly with individuals with mental illnesses.
• Working knowledge of managed care and various forms of healthcare delivery systems.
• Knowledge of specific review criteria and protocol sets.
• Ability to make sound clinical decisions independently.
• Strong organizational and prioritization skills.

Secondary Skills (Good To Have)

• Knowledge of Medicare guidelines and regulations.
• Familiarity with home health systems and medical review/processing procedures.
• Knowledge of database software and medical review systems.
• Working knowledge of Microsoft Excel, Access, or other spreadsheet/database tools.

Qualifications

• Degree Equivalency: Graduate of an Accredited School of Nursing (preferred).
• Required Work Experience:
  • 4 years of clinical experience; OR
  • 2 years of clinical experience and 2 years of medical review/utilization review; OR
  • Combination of health plan, clinical, and business experience totaling 4 years.
• Working knowledge of word processing and spreadsheet software.

Benefits/Perks

• Competitive compensation package.
• Opportunities for professional growth and career advancement.
• Exposure to diverse healthcare systems and managed care environments.
• A supportive and collaborative work culture.

Equal Opportunity Statement

Pulivarthi Group is proud to be an equal opportunity employer. We are committed to building a diverse and inclusive culture and celebrate authenticity. We do not discriminate on the basis of race, religion, color, national origin, gender, gender identity, sexual orientation, age, marital status, disability, protected veteran status, or any other legally protected characteristics.