Job detail

Clinical Reviewer (Part-time)

Neil Hoosier & Associates, Inc.

#Medical Coding #Microsoft Excel #Microsoft Teams #Medicare #CMS #CPT-4 #HCPCS #Healthcare Compliance #Clinical Documentation

Quick overview

Conduct clinical reviews of prior authorization and pre-payment requests for Fee-For-Service Medicare to ensure compliance with coverage and payment rules. Provide evidence-based clinical justifications for determinations and maintain organized documentation of assessments.

Requirements summary

Requires a licensed clinician (MD/DO, PA, NP, RN) with at least 5 years of professional healthcare experience and knowledge of Medicare guidelines. Medical coding certification and familiarity with CMS prior authorization programs are preferred.

professional certificatepostgraduate degreeQuality AssuranceWritten CommunicationMedical CodingMicrosoft Office SuiteClinical DocumentationCritical ThinkingCase ReviewSharePointOral CommunicationClinical ReviewMedical Necessity EvaluationMedicare Coverage Guidelines

Job description

Pay Range

$40 - $45 per hour based on experience
Work
Hours: 20 hours per week (Mon -
Fri)
Location: Remote

Summary

The Clinical Reviewer is responsible for conducting clinical reviews of submitted prior authorization (PA) requests and pre-payment requests submitted to Fee-For-Service Medicare by Providers and/or Suppliers. The reviewer verifies that each request includes accurate, complete clinical documentation and meets all applicable Medicare coverage, coding, and payment rules, including National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs). This role ensures that determinations are evidence-based, compliant, and aligned with the CMS requirements.

Responsibilities

and Duties: Review submitted prior authorization requests and/or pre-payment requests to determine whether required documentation is complete, accurate, and compliant with Medicare criteria. Evaluate medical necessity based on relevant NCDs, LCDs, and Local Coverage Articles as required for each item and/or service assessing clinical evidence provided. Provide clinical justification for affirmation or non-affirmation of accuracy decision Ensure all determinations align with Medicare requirements and CMS model rules Maintain thorough, organized documentation of clinical assessments, rationale, and determinations. Support quality reviews to ensure consistency and accuracy across determinations. Assist with writing review protocols, procedures, workflows, etc 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) Meet productivity and quality assurance standards Work in Project Manager to determine reviewer workload, tasking, and priorities

Qualifications

Licensed clinician (e.g., MD/DO, PA, NP, RN) At least 5 years of professional healthcare experience Working knowledge and understanding of Medicare 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 prior authorization programs, MAC processes, 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)