What are the responsibilities and job description for the Reviewer III, Medical position at Paladin Consulting?
Duties
- Performs medical reviews using clinical / medical information provided by physicians / providers and established criteria / protocol sets or clinical guidelines. Documents decisions using indicated protocol sets or clinical guidelines. Provides support and review of medical claims and utilization practices. 70% Performs medical claim reviews for one or more of the following : claims for medically complex services, services that require preauthorization / predetermination, requests for appeal or reconsideration, referrals for potential fraud and / or abuse, and correct coding for claims / operations.
- Makes reasonable charge payment determinations based on clinical / medical information and established criteria / protocol sets or clinical guidelines. Determines medical necessity and appropriateness and / or reasonableness and necessity for coverage and reimbursement. Documents medical rationale to justify payment or denial of services and / or supplies. 20% Educates internal / external staff regarding medical reviews, medical terminology, coverage determinations, coding procedures, etc. in accordance with contractor guidelines.
- 10% Participates in quality control activities in support of the corporate and team-based objectives. Provides guidance, direction, and input as needed to LPN team members. Provides education to non-medical staff through discussions, team meetings, classroom participation and feedback. Assists with special projects and specialty duties / responsibilities as assigned by Management.
Required Skills and Abilities :
Required
