Senior Clinical Reviewer

Senior Clinical Reviewer

Melbourne, FL | Orlando, FL | Hybrid

The range for this role is $31.97 per hour to $43.51 per hour. Actual base pay will be determined based on a successful candidate's work location, skills/abilities, experience, and education. Interested applicants must be willing and able to work onsite minimum 4 times per week in either our Melbourne, FL or Orlando, FL office.

The Job

The Senior Clinical Reviewer works to summarize and correlate concise, accurate information on medical reviews to determine eligibility of medical bills per the program guidelines. In this role, 70% of the time is spent performing pre-service and post-service medical reviews and/or reviews for high dollar, complex medical cases and collaborating with other departments to optimize cost savings. This position leverages AI-enabled clinical review tools and electronically ingested data (278 transactions) to enhance the accuracy, efficiency, and consistency of medical reviews. The Senior Clinical Reviewer will be expected to make decisions regarding timing and omission of medical reviews in deference to other department processes based on the dollar amount of the bill and the Ministry's cost strategy.

Essential Job Duties & Responsibilities

• Organize and review medical records, lab results, radiology, and pathology reports for conditions ineligible for sharing (CIF's)
• Determine eligibility of members' medical bills and/or upcoming procedures/treatments according to the program guidelines
• Perform pre-service and post-service medical reviews utilizing AI-enabled clinical review tools to make evidence-based, consistent, and efficient determinations of sharing eligibility
• Review and interpret pre-service eligibility data (via 278 EDI transactions) to support streamlined medical review workflows
• Integrate structured electronic data with clinical documentation to support accurate and timely eligibility determinations
• Collaborate with other departments to maximize cost savings for individual cases and optimal outcomes for the members
• Appropriately apply the program guidelines to the individual cases reviewed
• Work autonomously to prioritize and manage workload
• Document effectively in appropriate systems, including outputs supported by AI tools and electronic data ingestion processes
• Comply with all organizational HIPAA requirements and ensure proper handling of electronic transaction data
• Support process improvements related to automation, using AI tools and electronic data ingestion workflows
• Contribute to the exercise and expression of the Ministry's Christian beliefs
• All other duties as assigned

Essential Skills & Abilities

• Understanding of medical bill processing and provider bill negotiation
• Knowledge and practical application of AI-assisted medical review tools and clinical decision support technologies
• Ability to understand Availity 278 transactions and electronic pre-service eligibility workflows
• Ability to interpret structured electronic data and integrate it with clinical documentation during the medical review process
• Ability to multitask in multiple operating systems
• Ability to work for extended periods of time on the computer
• Proficiency in interpreting medical records and writing detailed reports and conclusions
• Strategic understanding of negotiations, third party processes, bill validation, and care management to determine when to utilize/defer to these processes for active review cases
• Ability to be objective and impartial and conclude a case
• Ability to communicate effectively with both internal and external customers
• Interpersonal skills and ability to work as a member of a team
• Ability to adapt to changing processes
• Working knowledge and application of program guidelines
• Understanding of systems and workflows as they relate to the type of review or assignment
• Ability to utilize the internet including e-mail and search engines
• Word processing skills of at least 25 wpm
• Basic knowledge in Microsoft Office (Excel, Word, Outlook, Teams) and ability to use a database system
• Knowledge of document imaging system

Core Competencies/Demonstrable Behaviors

• Action Oriented taking on new opportunities and tough challenges with a sense of urgency, high energy, and enthusiasm
• Plans and aligns planning and prioritizing work to meet commitments aligned with organizational goals
• Member First exhibits full commitment to serving members and/or clients by prioritizing their needs first in alignment with our program's purpose. This commitment is demonstrated through understanding of the program(s), provided through quality and timely service while exercising empathy in every interaction. Every CCM employee shares responsibility to steward resources faithfully, removing barriers to understanding, and creating accessible, connected, and Christ-centered experiences.
• Humble demonstrates Christ-Centered humility by honoring others, accepting feedback, and prioritizing collective success over individual recognition
• Hungry exhibits initiative, perseverance, and commitment to serving God through excellence. Demonstrates passion for personal and organizational growth while diligently advancing the mission of Christian Care Ministry
• Smart shows relational and emotional intelligence, communicates effectively, collaborates harmoniously, and reads social cues with grace and discernment

Education and/or Experience

• Current Unrestricted LPN/LVN license with 5+ years' experience in a healthcare payer industry or RN license with sound knowledge of anatomy and physiology and disease processes
• 1-3 years' experience in medical reviews required
• 2-3 years of clinical experience strongly preferred
• Experience with Utilization Review or Case Management preferred

Supervisory Responsibilities

• This job has no supervisory responsibilities

Incentives & Benefits

We work hard to serve our Medi-Share Members, but know we can only do that if we invest in our employees professionally, financially, physically, socially, and spiritually. We purposefully invest in our employees so that our employees can invest in others.

For full-time employees working 30 hours or more, some of our benefits include, but are not limited to:

• 100% paid Medical for employees/99% for family
• Generous employer Health Savings Account (HSA) contributions
• Employer-paid Life Insurance (3x salary) and Long-term Disability Insurance
• 6 weeks of paid parental leave (for both mom and dad)
• Dental - two plans to choose from
• Vision
• Short-term Disability
• Accident, Critical Illness, Hospital Indemnity
• 401(k) up to 4% match on ROTH or Traditional contributions
• Generous paid-time off and 11 paid holidays
• Wellness plan including Financial, Occupational, Mental/Spiritual, and Physical health incentives up to $50/mo
• Employee Assistance Program including no cost, in-person mental health visits and employee discounts
• Monetary Anniversary Awards Program
• Monetary Birthday Awards
• Tuition Reimbursement Program

Minimum Age Requirement: Due to the nature of the responsibilities associated with this positionincluding independent decision-making, access to confidential information, and potential exposure to regulated environmentscandidates must be at least 18 years of age at the time of hire. This requirement is in accordance with applicable federal and state labor laws and is intended to ensure compliance with workplace safety and legal standards.