Clinical Reviewer (Part-time)
$83,200–$93,600 year
Remote · Owings Mills, Maryland, United States
Job Summary
Clinical Reviewer (Part-time) conducts clinical reviews of submitted prior authorization and pre-payment requests for Medicare, verifying documentation and compliance with CMS rules (NCDs/LCDs). Evaluates medical necessity, provides clinical justification for determinations, ensures all reviews align with Medicare requirements, maintains thorough documentation, supports quality reviews, and assists with protocol/workflow development. Requires licensed clinician with Medicare knowledge; 20 hours/week, remote (Owings Mills, MD area), with 40-45 USD/hour pay range; familiarity with coding and CMS processes; able to participate in meetings and manage workload with project-management guidance.
Required Qualifications
- Licensed clinician (e.g., MD/DO, PA, NP, RN)
- At least 5 years of professional healthcare experience
- Working knowledge of Medicare coverage guidelines and ability to evaluate medical necessity
- 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 determinations
- Proficiency with Microsoft Office Suite (Outlook, Word, Teams, Excel) and SharePoint
- Must have no adverse actions pending or taken against any licensing board or program; must be legally authorized to work in the United States; no sponsorship provided by employer
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