Medical Reviewer – Medicare, Home Health

Job not on LinkedIn

🔥 0 minutes ago

🇺🇸 United States – Remote

💵 $62k - $65k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

🔍🏥 Medical Reviewer

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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 and 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 supporting approval or denial of services • Educate internal and external teams on medical review processes, coverage determinations, and coding requirements • Support quality control activities that advance corporate and team objectives • Assist with special projects and additional duties as assigned

🎯 Requirements

• Active, unrestricted RN license in the United States 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 plus at least two years in inpatient or outpatient settings, utilization or medical review, or quality assurance • Strong clinical background in managed care and/or inpatient and outpatient 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 • Ability to work independently while managing competing priorities • Excellent customer service, communication, and critical thinking skills • Ability to handle confidential information with discretion • Ability to pass background checks and drug testing prior to employment; some positions may require fingerprinting

🏖️ Benefits

• 401(k) and company match • PTO that grows the longer you stay • Health, Vision, Dental • Company provided Life Insurance and Voluntary Life Insurance • Short Term Disability and Long Term Disability