Medical Review Specialist III

Medical Review Specialist III

Requirements

• High School diploma or GED
• 2 – 4 years of related experience
• Strong knowledge of medical terminology and practices preferred

Responsibilities

• Supports peer-to-peer (P2P) processes, including scheduling P2P between Medical Directors and providers according to internal policies and requirements
• Manages and reviews Medical Director’s workflow queue in the medical management system and adjusts workflows as needed based on escalations and scheduling
• Schedules peer-to-peer (P2P) between Medical Directors and providers to discuss clinical services including the approval of a prior authorization
• Manages turn-around times for P2P authorizations to ensure P2P are conducted within a timely manner in accordance with regulations and policies
• Develops in-depth knowledge of P2P process, best practices, and internal policies and requirements
• Serves as front-line support in communicating with providers and/or vendors
• Provides support with all communications between clinical staff, providers, and Medical Directors
• Works with different teams to identify process improvements and efficiencies within the P2P process
• Performs other duties as assigned
• Complies with all policies and standards

Preferred Qualifications

• Strong knowledge of medical terminology and practices preferred