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 guideline... s 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.
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