Medicaid Medical Review SME

Job description

Medicaid Medical Review SME The Opportunity: As the Medicaid Medical Review SME, you will be in direct communication with the Medical Review Manager, Medical Reviewers, and client staff to provide expert clinical guidance and technical assistance, ensuring adherence to the Medical Review requirements. You will utilize extensive knowledge and proven ability to continually assess and evaluate clinical compliance with relevant regulations, both at a state and federal level. You will also be responsible for developing innovative solutions to complex problems. You’ll work without considerable direction and mentor and may supervise team members. Join us. The world can’t wait. You Have: 3+ years of experience practicing as a licensed Registered Nurse 3+ years of experience in a supervisory or managerial role in the health insurance industry, a utilization review firm , or health care claims processing organization, including performing medical and coding reviews of multiple medical and surgical claims from multiple provider types Experience performing MR, utilization, or QA reviews Knowledge of state and federal healthcare regulations, policies , coverage guidelines, and reimbursement rul...