Medical Claim Reviewer (CGS, DMEC-B)

of clinical experience.

pre- and post-payment medical reviews

to ensure compliance with established clinical criteria and guidelines.

The ideal candidate will use their clinical expertise to assess medical necessity, appropriateness, and reimbursement eligibility while documenting decisions in accordance with regulatory and organizational requirements.

medically complex claims

, pre-authorization requests, appeals, and fraud/abuse referrals.

Assess payment determinations using clinical information and established guidelines.