• Conduct comprehensive medical record reviews to assess medical necessity and compliance with established standards of care and applicable policies
• Manage end-to-end case screening processes, ensuring all activities are completed within established deadlines
• Document evidence-based criteria applicable to specific contract requirements
• Record and report screening results, including relevant referral questions, into a centralized database
• Evaluate medical claims against industry standards, utilizing research of relevant ICD-10, CPT, and HCPCS codes to determine medical necessity
• Maintain expert knowledge of evolving multi-state Medicaid policies and vendor expectations
• Participate in ongoing training and consistently meet or exceed productivity and quality assurance standards

• Medical terminology, ICD-10, CPT and HCPCS
• Clinical criteria (InterQual and MCG)
• Utilization/Medical record review and chart abstraction
• Current standards of medical practice
• Comply with HIPAA/HITECH laws and regulations

Experience in:

• At least three- five years performing medical record review and/or abstraction (Utilization Review experience preferred)
• Experience performing medical record review, audit for federal or state contracts
• Knowledge and experience of Medicare and Medicaid policy
• Proficiency with Microsoft Office (Word, Excel, and Outlook)
• Proficiency with Adobe PDF files and features
• Generating accurate, timely, and understandable correspondence
• Current experience (within the last 3 years) in the application of clinical screening criteria (InterQual and MCG)

Skills Requirements include:

• Professional interpersonal skills; ability to interact with providers, physicians and peers
• Solid analytical, assessment and documentation skills
• Effective written and verbal communication, both internally and externally
• Strong attention to detail
• Strong attention to deadlines
• Organizational skills including effective time management, priority setting and process improvement
• Ability to work independently and as a member of a team
• Adapt to changing work situations and readily adjusts schedules, tasks and priorities when necessary to meet business fluctuations

Educational Background:

• BSN with active RN licensure in good standing

Physical Demands: