Consultant - Medical (Case Reviewer 2)

Essential Duties and Responsibilities:
- Review cases and summarize the facts of each case and assess issues involved in the case to certify or non-certify requested treatments.
- Provide written clinical rationales for CA Workers Compensation cases.
- Review, organize and identify all medical records provided for CA workers comp cases.
- Monitor timeliness of reviews to ensure applicable standards are met.
- Consistently meet production and quality standards.
- Perform special projects as assigned such as legal research, general medical research, etc.
- Work on special projects to improve CA IMR project or other special projects as assigned.
- Become a subject matter expert (SME) using job aides and learning tools.

- Review and evaluate proposed Medicare set-aside arrangements, including submitted medical records, to determine if the proposed settlement meets the threshold requirements established for beneficiaries and potential beneficiaries and adequately considers Medicare's interests as pertaining to future medical service needs of beneficiaries.
- Ensure all basic documentation requirements are available or requested via development action prior to review by medical and pharmacy review personnel.
- Render medical/clinical determinations based on professional experience.
- Implement operating rules and CMS policy.
- Audit complex determinations for other clinical review programs utilizing medical records to ensure compliance with the organization's coding procedures and standards.
- Provide written clinical rationales for Workers Compensation cases.
- Review, organize and identify all medical records provided for workers comp cases.
- Other duties as assigned by management.

Minimum Requirements

- Bachelor's degree with 3-5 years of experience consulting within designated function.

- Extensive documentation review and/or medical review experience.

- Possess ample medical knowledge and experience with medical terminology, ICD-9/10 Codes, Current Procedure Terminology Codes (CPT) codes, with exposure to applying actual costs and workers' compensation fee schedules in pricing medical items and services.

- Availability during core business hours EST Monday - Friday.

- Ability to commit to a training period with zero absences (to include pre-planned vacations).

- Ability to pass a Federal Suitability Clearance.

Preferred Skills and Qualifications:

- Bachelor's degree from an accredited institution in Nursing, Pharmacy (PharmD), or other healthcare-related clinical discipline.

- Active, valid RN licensure.

- Medicare Set-Aside Certified Consultant (MSCC) certification (obtainable within 3 months of hire).

- Medical/Utilization Review experience.

- Medicare Set-Aside Arrangement experience.

Additional Knowledge of:

- Healthcare Common Procedure Coding System (HCPCS) coding practices.

- Medicare coverage guidelines.

- Anatomy, physiology, and pharmacology.

- Clinical practice guidelines.

- Utilization review standards and pract...