Case Reviewer

About the Role

As a Case Reviewer, you will oversee utilization reviews to determine service authorizations for Medicaid enrollees. Your responsibilities include applying program policies, verifying eligibility across medical, technical, and financial criteria, and examining medical records to make informed decisions on pre-authorization requests.

Training and Work Schedule

Initial training will be conducted at our Columbia, Maryland office, lasting approximately 3 to 6 weeks from Monday to Friday, 9 AM to 5 PM. Following training, attendance at quarterly on-site training sessions or team events is mandatory.

Key Responsibilities

• Make review decisions on prospective cases based on predetermined standards.
• Evaluate each case to ensure care appropriateness according to specific criteria.
• Refer cases that do not meet criteria to a Registered Nurse or Social Worker for further assessment.
• Complete thorough reviews within established deadlines.
• Act as an intermediary between clinical reviewers, providers, facilities, and subscribers.
• Record medical information supporting decisions accurately and timely in the documentation system.
• Deliver quality customer service by responding to email and phone inquiries from providers and consumers.

Candidate Requirements

• A bachelor's degree in health or human services with at least one year of utilization review or related healthcare policy/program experience OR a high school diploma/equivalent with a minimum of three years in similar experience.
• Proven skill in handling confidential information and meeting deadlines.
• Excellent communication, both verbal and written.
• Comfortable performing basic mathematics.
• Strong attention to detail, analytical capabilities, and ability to accurately interpret medical documentation.
• Intermediate computer skills, including navigating electronic health records and other software.
• Ability to work autonomously and collaboratively.
• Effective organizational and time management skills.
• Preferred experience in a community healthcare environment and utilization review of medical services.
• Completion of medical terminology coursework preferred.
• Familiarity with SharePoint and intermediate Excel proficiency is advantageous.
• Strong analytical and critical thinking abilities.