Clinical Reviewer - Medicare

(NOTE: This position is contingent upon contract award.) Pay Range: $60 - $65 per hour based on experience Work Hours: 20 hours per week/5 days Summary: A licensed healthcare professional—typically a nurse, physician, or other qualified clinician—who evaluates medical records, claims, and supporting documentation to determine whether services meet Medicare coverage, coding, and medical necessity requirements. Their work ensures that care billed to Medicare is appropriate, evidence-based, and compliant with federal regulations. Responsibilities and Duties: • Perform medical necessity determination of remote case files • Verify an adequate rationale for the decision is provided and the decision conforms to Medicare’s coverage guidelines, rules and regulations • Verify requirements are met, including reasonable and necessary adjudication, qualifications of reviewers, reviewing of medical records, steps in adjudication, determination of whether service is reasonable, and determination of whether service is necessary • Attend required meetings and workgroups as needed to perform independent case reviews (e.g., procedural changes, sharing trends, reviewing information on specific case files, and discussing issues or questions) • Utilize Internet resources for policy verification and regulations • Utilize application tools to document detailed evaluation finding • Meet productivity and quality assurance standards Qualifications: • Licensed clinician (e.g., MD/DO, PA, NP, RN) • At least 5 years of professional healthcare experience • Working knowledge and understanding of Medicare/Medicare Advantage coverage guidelines and clinical expertise to evaluate the medical necessity determination • Medical Coding Certification (ICD-9-CM, ICD-10-CM, CPT-4 and HCPCS) preferred • Ability to interpret clinical records, imaging, diagnostic tests, and practitioner notes. • Familiarity with CMS Medicare Advantage program and processes, MAC program and processes, prior authorization programs, or pre-payment medical review, preferred • Excellent clinical judgement and critical thinking. • Strong written and oral communication skills for documenting and communicating determinations. • Ability to work in a structured, time-sensitive environment. • High attention to detail and accuracy. • Proficiency with Microsoft Office Suite such as Outlook, Word, Teams, and Excel, and SharePoint • Must have no adverse actions pending or taken against him/her by any State or Federal licensing board or program • Must have no conflict of interest (COI) as defined in Section 1154(b)(1) of the Social Security Act (SSA) NHA is a state and federal government contractor; all employees must be legally authorized to work in the United States. NHA does not provide sponsorship at this time. NHA is an Equal Employment Opportunity employer. All qualified applicants will receive consideration for employment based on merit, without regard to race, color, religion, sex, sexual orientation, national origin, veteran status, disability or any other basis protected by law. Apply tot his job Apply To this Job