Comprehensive Case Reviewer

6 days ago

Manila, National Capital Region, Philippines beBeeAnalytical Full time ₱3,500,000 - ₱5,000,000
Medical Records Specialist Job Overview

We are seeking a skilled medical records specialist to fill this critical role. In this position, you will be responsible for preparing case reviews for Medical Directors and communicating with members, providers, and other departments regarding appeals requests.

Key Responsibilities:

  • Prepare case reviews for Medical Directors by researching the appeal, reviewing applicable criteria, and analyzing the basis for the appeal.
  • Ensure timely review, processing, and response to appeal in accordance with State, Federal, and NCQA standards.
  • Communicate with members, providers, facilities, and other departments regarding appeals requests.
  • Generate appropriate appeals resolution communication and reporting for the member and provider in accordance with company policies, State, Federal, and NCQA standards.
  • Work with leadership to increase the consistency, efficiency, and appropriateness of responses of all appeals requests.
  • Partner with interdepartmental teams to improve clinical appeals processes and procedures to prevent recurrences based on industry best practices.
  • Maintain files on individual appeals by gathering, analyzing, and reporting verbal and written member and provider appeals.
  • Review claim appeal for reconsideration and recommend approvals/denials based on determination level or prepare for medical review presentation.

Requirements:

  • 2-4 years of experience in processing appeals or utilization management.
  • RN - Registered Nurse – State required licensure and/or Compact State Licensure.
  • Knowledge of utilization management processes.
  • Knowledge of NCQA, Medicare, and Medicaid regulations.
  • Good communication skills (demonstrate strong reading comprehension and writing skills).
  • Able to work independently, strong analytic skills.

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