Physician Emergency Department Claims Reviewer

Required skills: Physician with an active US licensed with experience in with medical coding (CPT/HCPCS) and managed care to conduct clinical review of claims and UM authorization requests for clinical necessity.Minimum of recent (last 2-3 years) 3-5 clinical experience in emergency dept medicine, experience in internal medicine will be considered. Experience in managed care, clinical UM case reviews. Knowledge of claims and medical coding (CPT/HCPCS codes). Proficient working in various system

Job Title - Medical Director (with active medical state licensure required for PA, NY, or WV) Location Remote Duration 6 months Contract with the possibility of contract-to-hire Medical Director Job Description This job, as part of a physician team, ensures that utilization management responsibilities are performed in accordance with the highest and most current clinical standards. The incumbent reviews escalated cases electronically and using Medical Policy criteria sets to evaluate the medic

As aPre-AuthConsultantyou will be a part of an Agile team to build healthcare applications and implement new features while adhering to the best coding development standards . Mandatory skills FACETS UM/Pre-Auth Configuration ITS/Authorization Routing Logic SQL & Rule Traceability Responsibilities: - 7 - 10 years in UM/Pre-Auth configuration within FACETS. Familiarity with UM workflows, clinical guidelines, and state mandates. Experience working with clinical/utilization management stakeho

Responsibilities: Reviews medical records/case file, writes a reconsideration decision letter that is clear, concise, andimpartial and supports the determination made, and documents review.Makes sound, independent decisions based on medical evidence in accordance with statutes, regulation,rulings, and policy.Responds to and ensures that all appeal issues raised by the beneficiary/patient, representative, andprovider/supplier have been addressed.Provides a fair and impartial decision based on cu