Clinical Reviewer

Pay Range :

• $80K - $85K annually based on experience 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 :

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 :

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.