Medical Reviewer

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🔥 0 minutes ago

🇺🇸 United States – Remote

💵 $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

• Handle claim types including Radiology, Ambulance, Physical Therapy, and Surgical • Use clinical information, Medicare guidelines, and established criteria to determine medical necessity, coverage, and payment • Document medical review decisions and the rationale supporting payment or denial of services and supplies • Review medically complex claims, preauthorization or predetermination requests, appeals and reconsiderations, potential fraud and abuse referrals, and correct coding reviews • Educate internal and external staff on medical review, terminology, coverage determinations, and coding • Provide guidance and direction to LPN team members as needed • Participate in quality control activities • Assist with special projects and specialty assignments as directed by management

🎯 Requirements

• Active, unrestricted RN license in the U.S. and in the state of hire, or an active, unrestricted multistate RN license under the Nurse Licensure Compact • Associate’s degree in nursing or graduate of an accredited school of nursing • 2 years of clinical experience plus 2 years in utilization or medical review, quality assurance, or home health • Home health, rehabilitation, and/or broad medical-surgical experience • Working knowledge of criteria and protocol sets, managed care, and health care delivery systems • Proficiency in Microsoft Office • Strong written and verbal communication • Sound judgment and critical thinking • Ability to work independently, prioritize, and handle confidential information • Must be able to pass the CMS background investigation and complete fingerprinting and EUA/system access clearance in a timely manner • Must live within a three hour driving radius of Augusta, GA

🏖️ 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 • Comprehensive benefits package