Reviews medical records, order documentation, and supporting clinical information to assess completeness, consistency, and alignment with medical necessity and payer criteria.
Key responsibilities include:
- Reviewing medical records, order documentation, payer criteria, and related support materials for completeness and consistency
- Comparing submitted documentation against insurance medical necessity criteria, internal review standards, and workflow instructions
- Identifying missing, incomplete, inconsistent, or unclear documentation and communicating findings to internal teams
- Documenting review outcomes accurately in designated systems, trackers, or case management tools
- Preparing clear written summaries of findings with specific references to supporting or missing information
- Maintaining confidentiality of patient, provider, and order information
- Following escalation pathways when additional review or supervisor guidance is needed
- Meeting productivity, accuracy, and quality expectations
- Submitting medical authorizations based on payer preferences and following up until determination is made
- Participating in training, calibration sessions, and process updates
- Performing other documentation review and administrative support duties as assigned
Requirements & Qualifications
Required
- High school diploma or equivalent required; associate degree or relevant healthcare coursework preferred
- Minimum of 3 years of experience reviewing and interpreting medical records, order documentation, clinical documentation, insurance documentation, or related healthcare records
- Working knowledge of medical terminology and the ability to understand documentation related to patient history, diagnoses, treatment plans, orders, and supporting clinical notes
- Strong attention to detail and ability to identify documentation gaps, inconsistencies, and discrepancies
- Excellent written and verbal communication skills
- Ability to follow established criteria, checklists, standard procedures, and supervisory direction
- Proficiency with Microsoft Office applications and ability to learn order management, documentation, or case management systems
- Ability to manage multiple cases or tasks while meeting timelines and quality expectations
Preferred
- Experience reviewing documentation for insurance medical necessity, prior authorization, utilization review support, durable medical equipment, home health, specialty pharmacy, or related order management processes
- Experience using electronic medical record systems, payer portals, order management platforms, or document management tools
- Familiarity with payer guidelines, coverage policies, audit documentation, or medical review workflows
Location
Denver, Colorado, US
Employment Type
Not specified
Experience Level
Intermediate Level
Remote work allowed
No
Posted
4 weeks ago