• Job Description

  Req#: 154e5303-9a81-43d7-b865-b6bf8fd21a98
  Clinical Review Specialist - Contract! (40 Hrs./Week)
  
  Department: Medical Affairs
  
  Employment Type: Contract
  
  Location: Remote, U.S.
  
  Compensation: $35.00 - $40.00 / hour
  
  Description
  
  The Clinical Review Specialist utilizes clinical expertise to review patient medical records, ultimately determining that medical necessity has been established. This team member is responsible for composing prior authorization requests, crafting appeals and reviewing specific insurance policies.
  
  The ideal candidate displays strong attention to detail, excellent verbal and written communication skills, and exhibits a diligent follow-up practice.
  
  Responsibilities
  
  • Manage and monitor patient caseload, ensuring timely adherence to insurance deadlines.
  • Review patient medical records to ensure they meet medical necessity criteria for Myomo products.
  • Compose prior authorization requests, ensuring that clinical documentation follows Medicare compliance and guidelines.
  • Craft written appeals in response to insurer specific denials, completing insurer-specific appeal forms for patient signatures.
  • Analyze and address insurance denials and authorizations, accurately documenting patient status and updates in the CRM.
  • Review patient medical records to initiate Administrative Law Judge (ALJ) Hearings when necessary.
  • Audit payer policies and update internal resources as needed; safeguard strict adherence to HIPAA regulations as well as organizational compliance standards.
  • Meet with management regularly for updates, feedback and performance metrics.
  • Develop and update resources on insurance policies, operational strategies, and authorization/denial trends in collaboration with management.
  • Facilitate intra/interdepartmental communication, ensuring process alignment.
  • Assist in training new staff as needed, attending department and company meetings as scheduled.
  • Meet productivity expectations, as outlined in performance goals.
  
  
  Requirements
  
  • Graduate degree from an accredited occupational /physical therapy, physician assistant, or nursing program.
  • 2-4+ years of direct patient care experience with patients who commonly suffer upper extremity weakness as a result of illness/injury.
  • Health insurance reimbursement and/or medical device industry experience highly desirable.
  • Well-versed in medical terminology, as well as in reading/interpreting medical records from various physician specialties and allied health professionals.
  • Strong understanding of and comfort with ICD-10 codes.
  • Proficiency with computer programs (e.g., MS Office, Adobe, various EMR platforms)
  • Excellent written/verbal, interpersonal, and organizational skills with strong attention to detail.
  • Comfort in a fast-paced setting, with the ability to prioritize and adapt amid an evolving work environment.
  • Ability to meet deadlines with specified time constraints.
  • Ability to work both collaboratively and cross-functionally, as well as independently.

• About the company

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