Referral Reviewer

Job description

Position Overview The Referral Coordinator Reviewer is responsible for reviewing medical referrals to determine medical necessity and ensure compliance with CMS (Centers for Medicare & Medicaid Services) guidelines and criteria. This role involves thorough evaluation of referral documentation, application of clinical guidelines, and collaboration with healthcare providers to facilitate appropriate patient care. Key Responsibilities: - Review and assess medical referrals to establish medical necessity based on CMS guidelines and other guidelines. - Apply clinical guidelines and criteria to ensure referrals meet established standards. - Communicate with healthcare providers to obtain additional information or clarification as needed. - Document review findings and decisions accurately in the appropriate systems. - Collaborate with other healthcare team members to ensure coordinated and efficient patient care. - Maintain up-to-date knowledge of CMS guidelines and criteria. - Participate in quality improvement initiatives and training sessions. - Ensure compliance with all regulatory and organizational policies and procedures. Qualifications: - Foreign Medical graduate (preferred) - Pr...