Medical Claims Review Analyst

About the role

Provides clinical review expertise for high dollar and complex claims, including facility and professional bills. Provides cost containment services by identifying coding and billing errors and insuring application of Medical and Reimbursement Policies. Additionally identifies cases for potential fraud and abuse and makes referrals.

What you'll do

• Evaluates medical information against criteria, benefit plan, coverage policies and determines necessity for procedure and refers to Medical Director if criteria are not…
• Evaluate itemized bills against reimbursement policies
• Adheres to quality assurance standards
• Handles some escalated cases; secures supervisory assistance with problem solving and decision making
• Advises supervisory staff of any concerns or complaints expressed by Health Care Professionals

What you need

• Excel
• MBBS