Description
Healthcare Medical Reviewers Description – Conducts clinical reviews of medical records during the course of Healthcare claim/case reviews and fraud investigations… Apply healthcare coverage guidelines and reimbursement rules in making clinical determinations as to the medical necessity and appropriateness of services rendered and billed and corresponding payment determinations. Requirements – Bachelor’s degree in healthcare or related field preferred or equivalent combination of education and experience. Active license as a Registered Nurse (RN). Medical review and/or utilization/quality assurance review and ICD-9-CM/CPT coding experience. Knowledge of medical terminology and experience in the analysis and processing of medical insurance, worker compensation and/or long term disability rules and regulations preferred.