Medical Review Specialist III

About the Role

Key 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.

Requirements

• Requires a High School diploma or GED.
• Requires 2 - 4 years of related experience.
• Strong knowledge of medical terminology and practices preferred.

Qualifications

• High School diploma or GED
• 2 to 4 years of related experience

Benefits & Perks

• Competitive pay
• Health insurance
• 401K and stock purchase plans
• Tuition reimbursement
• Paid time off plus holidays
• Flexible work options including remote, hybrid, field, or office schedules