Case Reviewer

Job Description

Job Description

Absolute Staffing & Consulting Solutions is looking for a Case Reviewer to join our team of professionals. This is a hybrid, work-from-home position for candidates residing within commuting distance of Columbia, Maryland. While the position is performed remotely Monday through Friday, employees are expected to attend quarterly in-person trainings and meetings at our client’s Columbia, MD office. If you’re looking for the flexibility of working from home while remaining connected to a collaborative team, we’d love to hear from you!

Position Summary

As a Case Reviewer, you will be responsible for performing utilization reviews to authorize services for individuals enrolled in Medicaid. The utilization review process involves applying program policies, verifying medical, technical, and financial eligibility, and reviewing medical records to issue decisions regarding pre-authorization of services. 

 

Essential Functions

• Provides review decisions for prospective reviews based on an established set of criteria.
• Screens situations according to specific criteria to determine if care is appropriate.
• Refers cases that fail to meet criteria to a Registered Nurse or Social Worker reviewer.
• Ensures review is conducted thoroughly and within specified timeframes.
• Serves as liaison among clinical reviewer, provider, facility, and/or subscriber.
• Documents medical information supporting decisions into the workflow documentation system, ensuring data is entered accurately and timely.
• Ensures quality customer service by responding to email and phone inquiries from providers and consumers.

Requirements

• Bachelor’s degree in the health or human services and at least 1 year of experience in utilization review or 1 year of experience evaluating, analyzing, researching and developing health care services, policies and programs preferred.
• Demonstrated ability working with confidential information and in a deadline-driven environment.
• Excellent verbal and written communication skills
• Comfortable with completing basic math functions.
• Attention to detail, analytical skills, and the ability to interpret medical documentation accurately.
• Possess intermediate PC skills including navigating electronic health records and other computer software.
• Ability to work independently and as part of a team.
• Organizational skills and time management.
• Experience in a community health care environment preferred.
• Experience with utilization review of medical services preferred.
• Satisfactory completion of medical terminology course preferred.
• Must reside within a reasonable commuting distance of Columbia, Maryland to attend required quarterly in-person trainings and team meetings.
• Reliable transportation to the Columbia, MD office for scheduled quarterly onsite meetings is required.

 

Preferred Skills and Certifications

• Proficiency with Sharepoint
• Possess intermediate skills in Excel
• Strong analytical and critical thinking skills
• Previous support planner experience a plus

Shift & Work Location

• Monday–Friday 8:00 am- 5:00 pm EST (Remote, Work from Home)
• Required: Quarterly attendance for in-person training sessions on site in Columbia, MD. *Advance notice will be provided for all onsite training dates

Base Pay :

$23- $27/ hour

Why work for our client?

Our client is one of the country's most respected population health management organizations. They work with state and federal government programs, as well as employers and health plans offering clinical, analytical, and technical expertise.

Health has changed a lot through our 50-year history, but what has remained constant is that they care deeply about who they serve and what they do. Their success is built on their ability to adapt, respond to client needs, and offer innovative solutions at every turn.

Our client is looking for talented individuals who not only believe in the mission, but who are ready to take ownership and make a difference in the lives of people, in the world of health.