Medical Review Specialist

General Description Responsible for conducting clinical reviews of post-service and pre-payment claims requiring medical documentation to determine medical necessity, coding accuracy, reimbursement appropriateness, and compliance with clinical guidelines, payment policies, and regulatory requirements. Applies clinical judgment, critical thinking, and reimbursement knowledge to support accurate claim determinations, cost containment initiatives, and payment integrity. Regular, Exempt Essential Functions Conducts clinical reviews and analyses of complex medical records, ancillary services, appeals, and claims requiring clinical documentation to determine medical necessity, coding accuracy, and reimbursement appropriateness, applying clinical judgment and critical thinking in the review of initial determinations and appeals. Investigates and evaluates claims using applicable systems, clinical guidelines, payment policies, coding rules, and provider agreements to support accurate determination and payment integrity, integrating knowledge of reimbursement to ensure accurate claim outcomes. Performs clinical and telephonic interventions with providers to validate medical necessity, request additional documentation, discuss clinical scenarios, and support claim determinations, providing guidance and sharing knowledge with providers and internal stakeholders regarding clinical determinations and documentation requirements. Identifies cost-containment opportunities, inappropriate billing patterns, overpayments, and potential fraud, waste, or abuse situations, escalating cases when applicable, including evaluation of cost drivers such as high-cost diagnostics, transportation, and NCCI-related edits, supporting cost savings initiatives. Documents case findings, recommendations, rationales, and referral information accurately while maintaining evidence and records according to departmental standards, ensuring documentation meets audit and compliance requirements. Collaborates with internal departments and participates in meetings, projects, and operational initiatives to support service quality, compliance, and effective claims review operations. Refers cases to Medical Policy or other appropriate departments when clinical review identifies policy gaps or requires further evaluation. Must comply fully and consistently with all company policies and procedures, with local and federal laws as well as the regulations applicable to our industry, to maintain appropriate business and employment practices. May carry out other duties and responsibilities as assigned, according to the requirements of education and experience contained in this document. Minimum Qualifications Education and experience: Bachelor's degree in Nursing Sciences. At least two (2) years of clinical nursing experience required. Experience in utilization review, payment integrity, claims review, case management, managed care, or healthcare reimbursement operations preferred. Knowledge of CMS guidelines, coding methodologies, and medical necessity review processes preferred. Certifications / Licenses: A valid License and Registration of Nurse & Association Nursing Professionals of Puerto Rico are required. Other: Extensive knowledge of medical terminology and experience in ICD-10 and CPT coding is preferred. Languages: Spanish – Intermediate (comprehensive, writing and verbal) English – Intermediate (comprehensive, writing and verbal) “We are an Equal Employment Opportunity Employer and take affirmative action to recruit Protected Veterans and Individuals with Disabilities.” #J-18808-Ljbffr MCS Puerto Rico