Medical Review Analyst II
Elevance Health

Job Info

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Medical Review Analyst II

Location: This is a remote position. Ideal candidates will live within 50 miles of one of our PulsePoint office locations.

Work Hours: This is a day shift working Monday through Friday. Holidays, evenings, and weekends may be required based on business needs.

The Medical Review Analyst II is responsible to provide non-clinical review and analysis of all non-complex and some complex Tier I post service medical claims.

How you will make an impact :

• Utilizes guidelines and review tools to analyze assigned claims and medical records to either approve or summarize and route to nursing and/or medical staff for review.
• Reviews, analyzes and renders determinations on assigned non-complex and some complex Tier I requests.
• Serves as a liaison between medical management and/or service operations and other internal departments.
• Serves as an internal resource for associates.
• Responsibilities exclude conducting any utilization or medical management review activities which require the interpretation of clinical information.
• Prepares cases for clinical review and completes reviews using nonclinical scripts.

Minimum Requirements:

• Requires a HS Diploma or equivalent and a minimum of 5 years of claims processing or customer service experience with managing complex claims, provider, or member issues; or any combination of education and experience which would provide an equivalent background.
• Experience with medical coding and medical terminology required.
• Knowledge of provider networks, the medical management process, internal business processes, and proficiency with internal local technology required.

Preferred Skills, Capabilities & Experiences:

• Self-motivated, independent, flexible, and ready to learn new applications and processes.
• Strong oral, written and interpersonal communication skills, problem-solving skills.
• Proficient use of computers and multiple monitors.
• Experience with Microsoft applications such as Outlook, Word, Excel, OneNote and MS Teams is preferred.
• Experience working in a production environment
• Experience working in ACMP, GBD Facets, Macess and NextGen is preferred.
• BA/BS preferred.
• Claims processing experience preferred

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