Medical Reviewer

Job not on LinkedIn

🔥 1 minute 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/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 • 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 • Minimum two years of clinical experience plus at least two years in one of the following: Inpatient/Outpatient settings; Utilization/Medical Review; Intensive care (ICU/ER); Quality Assurance • Familiarity with Medicare Part A/B/HHH guidelines • Strong clinical background in managed care and/or inpatient/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 priorities effectively • Excellent customer service, communication, and critical thinking skills • Ability to handle confidential information with discretion • Must have lived in the United States for at least 3 out of the last 5 years to pass the required background check • Private home office with high-speed, hardwired internet • Fiber internet; 5G satellite home internet is not permitted • Must pass background check and drug testing prior to start; 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 • Reasonable accommodations are available for applicants with disabilities