Medical Review Specialist

 

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
• Performs other related duties as assigned

EDUCATION

• High School Diploma or GED required

 

 

EXPERIENCE AND SKILLS

• Must have a minimum 4 years of comprehensive experience with the handling of medical claims or working with medical data required.
• Coding experience and knowledge required.
• Must have the ability to analyze claim situations and take appropriate actions.
• Must possess excellent verbal and written communication skills.
• Must have experience with Microsoft Word, Excel, Access and Outlook.

 

COMPETENCIES

• Communication
• Customer Focus
• Accountability
• Functional/Technical Job Skills

 

PHYSICAL DEMANDS

• This is an office environment requiring extended sitting and computer work

 

WORK ENVIRONMENT

• Remote

 

Here at Allied, we believe that great talent can thrive from anywhere. Our remote friendly culture offers flexibility and the comfort of working from home, while also ensuring you are set up for success. To support a smooth and efficient remote work experience, the internet connection must be obtained through a cable broadband or fiber optic internet service provider with speeds of at least 100Mbps download/25Mbps upload. Reliable internet service is essential for staying connected and productive.

The company has reviewed this job description to ensure that essential functions and basic duties have been included. It is not intended to be construed as an exhaustive list of all functions, responsibilities, skills, and abilities. Additional functions and requirements may be assigned by supervisors as deemed appropriate.

Compensation is not limited to base salary.  Allied values our Total Rewards, and offers a competitive Benefit Package including, but not limited to, Medical, Dental, Vision, Life & Disability Insurance, Generous Paid Time Off, Tuition Reimbursement, EAP, and a Technology Stipend.

Allied reserves the right to amend, change, alter, and revise, pay ranges and benefits offerings at any time.  All applicants acknowledge that by applying to the position you understand that the specific pay range is contingent upon meeting the qualification and requirements of the role, and for the successful completion of the interview selection and process.  It is at the Company's discretion to determine what pay is provided to a candidate within the range associated with the role.

 

Protect Yourself from Hiring Scams

Important Notice About Our Hiring Process

 

To keep your experience safe and transparent, please note:

• All interviews are conducted via video.
• No job offer will ever be made without a video interview with Human Resources and/or the Hiring Manager.

If someone contacts you claiming to represent us and offers a position without a video interview, it is not legitimate. We never ask for payment or personal financial information during the hiring process.

 

For your security, please verify all job opportunities through our official careers page:

 

Your security matters to us—thank you for helping us maintain a fair and trustworthy process!