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Medical Review Specialist

Allied Benefit Systems

This is a Contract position in Houston, TX posted August 27, 2021.

Description Job Title: Medical Review Specialist Department: Medical Review Department FLSA Status: Exempt Job Status: FT Reports To: Supervisor, Claim Operations Positions Supervised: N/A Work Schedule: Flexible full-time hours Assessments: Predictive Index Cognitive and Behavioral Position Summary Review and analyze referrals and supporting documentation to determine medical necessity of medical and dental services.

Review medical appeals, pre-determinations, and medical necessity referrals to be sent to an outside vendor for review.

Compose approval and denial letters as deemed appropriate.

Essential Functions Review urgent referrals and Plan renewals to determine Medical Necessity Review Summary Plan Documents to determine coverage/exclusions prior to prepping referral Document the QicLink system and database to show referrals received and sent to vendors as well as determinations made within the unit Respond to all inquiries sent to the department by other departments and from vendors Determine medical necessity on injectable medication when necessary Compose response letters to providers and members, and ensure the letters meet the specific Plan requirements and timeframes Communicate with examiners, other departments and the clients when necessary Prioritize incoming referrals to complete all tasks timely Support with inventory numbers and performs follow up on outside reviews to insure prompt TAT on referrals Support the logging, faxing, and posting of referrals Support the prepping of invoices and follow up on outstanding invoices when necessary Other duties as assigned Position Qualifications Communication – Communicates effectively both internally and externally, where applicable.

Includes both written and verbal communication.

Customer Focused – Works well with customers/clients both internal and external, promotes a positive image of the company and department, and strives to solve issues raised by customers.

Dependability – Meets deadlines, works independently, accountable, maintains focus, punctual, and maintains good attendance record.

Initiative – Takes action independently, seeks new opportunities, and strives to see projects to completion.

Interpersonal Skills – Builds strong relationships, is flexible/adaptable, works well with others, and solicits feedback.

Job Knowledge – Understands the facets of job, aware of duties and responsibilities, and keeps job knowledge current.

Organization Skills – Information organized and accessible maintains efficient work space, and manages time well.

Problem Solving – Strives to understand contributing factors, works to resolve complex situations.

Productivity – Manages workload, works efficiently, and meets goals and objectives.

Self-Development – Looks for opportunities to increase knowledge, works to increase responsibility, strives to achieve personal goals and/or maintains licenses and other pertinent requirements.

Sense of Urgency – Meets deadlines, establishes appropriate priority, and completes tasks assigned in timely manner.

Teamwork – Accountable to team, works to meet established deliverables, appreciates view of team members, and respectful.

Technical Skills – Maintains current understanding of technical process/equipment, uses technology to increase performance/productivity; effectively uses online tools and resources.

Skills & Abilities Microsoft Word, Excel, Access and Outlook.

Experience Applicants must have 4 years or more of comprehensive experience with the handling of medical claims or working with medical data.

The applicant must have the ability to analyze claim situations, take appropriate actions and be great with communication and documentation.

Coding experience and knowledge required.

Education High School Education required.

PHYSICAL DEMANDS Ability to sit for long periods of time, perform computer work WORK ENVIRONMENT Flexible hours, ability to work from home upon tenure requirements and approval from manager.

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