Medical Claim Reviewer, CGS, DMEC

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🕒 June 24

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Simsy Ventures

WebsiteLinkedInAll Job Openings

11 - 50 employees

Founded 2022

💼 Consulting

📣 Marketing

🏥 Healthcare

Consulting • Marketing • Healthcare

Simsy Ventures is a venture builder and institutional co-founder that partners with entrepreneurs, investors, and corporations to create sustainable startups. Their mission focuses on enabling startups to achieve true potential while promoting a positive impact on profits, people, and the planet. With a structured approach, they support startups throughout their lifecycle, from ideation to market validation and growth. By leveraging a repeatable venture studio model, Simsy Ventures aims to uplift economies globally through impactful entrepreneurship.

📋 Description

• Review medically complex claims, pre-authorization requests, appeals, and fraud/abuse referrals. • Assess payment determinations using clinical information and established guidelines. • Evaluate medical necessity, appropriateness, and reasonableness for coverage and reimbursement. • Provide clear, well-documented rationales for service approvals or denials. • Educate internal and external teams on medical review processes, coverage determinations, and coding requirements. • Support quality control activities to meet corporate and team objectives. • Provide guidance to LPN team members and support non-clinical staff through training and discussions. • Assist with special projects and additional responsibilities as assigned.

🎯 Requirements

• Active, unrestricted RN license in the U.S. and in the state of hire OR • Active compact multistate RN license (as defined by the Nurse Licensure Compact). • Associate Degree in Nursing OR • Graduate of an accredited School of Nursing. • Two years of clinical experience. • Strong clinical background in managed care, home health, rehabilitation, and/or medical-surgical settings. • Ability to interpret and apply medical review criteria and clinical guidelines. • Proficiency in Microsoft Office and word processing software. • Strong analytical, organizational, and decision-making skills. • Excellent customer service, communication, and critical thinking skills. • Ability to handle confidential information with discretion.

🏖️ Benefits

• Health insurance • 401(k) matching • Flexible work arrangements • Professional development opportunities • Equipment provided for work