Clinical Reviewer (Part-time) Job at Neil Hoosier & Associates, Inc., Owings Mills, MD

bVJjamt5RmRaRTNuS1dHMXF6ek9BNk5VT1E9PQ==
  • Neil Hoosier & Associates, Inc.
  • Owings Mills, MD

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)

 

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.

Job Tags

Hourly pay, Part time, For contractors, Work at office, Local area

Similar Jobs

Moonlight Companies

Food Safety Technician (PM Shift) Job at Moonlight Companies

 ...Job Title: Food Safety Technician (PM Shift) Department: Food Safety Shift: PM Shift Location: Kerman Position Summary The Night Food Safety Technician is responsible for ensuring that all food safety and sanitation standards are maintained during night shift... 

Voodoo

3D/2D Game Artist (Unity) Job at Voodoo

 ...Role Support the Art Director in the ideation and execution of the games vision. Create high-quality 3D/2D assets (characters, assets, props and environment art) and ensure optimal performance across mobile devices. Setup, integrate, and animate UI scenes in... 

Confidential

Anesthesiology Locum Tenens - North Carolina Job at Confidential

 ...Your Next Anesthesiology Locum Tenens Assignment in North Carolina ~ Call Coverage Needed: ~1/19 start at 3:00PM2/2 end at 3:00PM ~2/16, start at 3:00PM3/2, end at 3:00PM ~3/16 start at 3:00PM3/30 end at 3:00PM Setting: Inpatient & Outpatient Call... 

Dairy Queen

Cake Decorator Job at Dairy Queen

 ...the Dairy Queen brand and be professional in every aspect of performance Bring to life fans' imagination through the art of cake decorating Assemble and prepare soft serve and Blizzard cakes, including decorating with icing, gel, drawings, decorating kits, air brush... 

Confidential

Helium Logistics Analyst Job at Confidential

 ...respectful environment that values inventiveness and professional growth. This position offers a fantastic opportunity to sharpen your supply chain skills, manage complex global networks, and tackle real-world energy and logistics challenges. INTERESTED? APPLY NOW!...