Clinical Reviewer
Remote
Full Time
Experienced
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:
Qualifications:
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:
- Review submitted prior authorization requests and/or pre-payment requests to determine whether required documentation is complete, accurate, and compliant with Medicare criteria.
- Evaluate medical necessity based on relevant NCDs, LCDs, and Local Coverage Articles as required for each item and/or service assessing clinical evidence provided.
- Provide clinical justification for affirmation or non-affirmation of accuracy decision
- Ensure all determinations align with Medicare requirements and CMS model rules
- Maintain thorough, organized documentation of clinical assessments, rationale, and determinations.
- Support quality reviews to ensure consistency and accuracy across determinations.
- 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:
- Licensed clinician (e.g., MD/DO, PA, NP, RN)
- At least 5 years of professional healthcare experience
- Working knowledge and understanding of Medicare coverage guidelines and clinical expertise to evaluate the medical necessity determination
- Medical Coding Certification (ICD-9-CM, ICD-10-CM, CPT-4 and HCPCS) preferred
- Ability to interpret clinical records, imaging, diagnostic tests, and practitioner notes.
- Familiarity with CMS prior authorization programs, MAC processes, or pre-payment medical review, preferred
- Excellent clinical judgement and critical thinking.
- Strong written and oral communication skills for documenting and communicating determinations.
- Ability to work in a structured, time-sensitive environment.
- High attention to detail and accuracy.
- Proficiency with Microsoft Office Suite such as Outlook, Word, Teams, and Excel, and SharePoint
- Must have no adverse actions pending or taken against him/her by any State or Federal licensing board or program
- Must have no conflict of interest (COI) as defined in Section 1154(b)(1) of the Social Security Act (SSA)
NHA is a state and federal government contractor; all employees must be legally authorized to work in the United States. NHA does not provide sponsorship at this time.
NHA is an Equal Employment Opportunity employer. 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.
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