Medical Claims Reviewer - Augusta - Broadway Ventures

    Broadway Ventures
    Broadway Ventures Augusta

    19 hours ago

    Description

    Job Responsibilities

    • Performs medical claim reviews for one or more of the following: claims for medically complex services, services that require preauthorization/predetermination, requests for appeal or reconsideration, referrals for potential fraud and/or abuse, and correct coding for claims/operations.
    • Makes reasonable charge payment determinations based on clinical/medical information and established criteria/protocol sets or clinical guidelines.
    • Determines medical necessity and appropriateness and/or reasonableness and necessity for coverage and reimbursement.

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