Medical Reviewer III – Ohio

Job Summary

A company is looking for a Medical Reviewer III for a Managed Care Project (MCP) – REMOTE.

Key Responsibilities:

• Contribute to the development of review criteria for claims based on Medicaid guidelines
• Review project plan information to ensure correct payment of claims and documentation support
• Collaborate with healthcare professionals, regulatory agencies, and law enforcement personnel

Required Qualifications:

• Active license as a Registered Nurse (RN) from an accredited school of nursing
• 4 years’ experience in utilization/quality assurance review and ICD-10-CM/CPT-4 coding
• 4 years’ experience in coding and abstracting, including knowledge of Diagnosis Related Groups (DRGs)
• Advanced knowledge of medical terminology, Medicaid claims processing, and payment methodologies
• Experience in Medicaid coverage guidelines and utilization review/quality assurance procedures