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Review Analyst I (Medical Management)


Posted: 10/2/2019
Job Reference #: 5000523983006

Job Description

Employment Type


Exempt or Non-Exempt


Job Summary

Analyze, research and manage authorization requests from private lines of business for medical review by interpreting applicable medical policies, benefit guidelines, regulatory guidelines and department standards related to contractual and accreditation requirements.

Minimum Qualifications

  1. Associates degree and one year of related work experience or equivalent combination of education and/or experience
  2. Working proficiency with Microsoft Office applications.
  3. Excellent customer service skills to respond appropriately to internal and external inquiries and concerns.
  4. Excellent verbal and written communication skills.

Duties and Responsibilities

  1. Analyzes, researches and interprets medical and claims data while processing authorization requests.
    • Authorizes requests that clearly meet specified criteria according to department guidelines.
    • Refers requests to Medical Directors for determination when appropriate following department and regulatory guidelines.
    • Ensures necessary medical record information, previous review determinations and other member-specific data are sufficient to make determinations.
    • Requests any missing information according to medical policy and benefit guidelines following department standards and regulatory statutes.Ensures requests are processed within regulatory timeliness guidelines.
    • Maintain productivity rate and meet requirements for accuracy and timeliness for Private Business.
  2. Communicates final case determinations in writing and by telephone providing complete and accurate information using appropriate templates per department and regulatory guidelines. Documents accurately and completely in a timely manner.
  3. Resolves incoming routine inquiries from members and providers received by telephone, correspondence or email.
  4. Ensures quality outcomes by tracking, researching and documenting updated benefit/medical policy information, unit workflows and inquiry resolution as well as participating in quality improvement activities such as inter-rater reliability reviews.
  5. Complete other duties as assigned.