Medical Review Analyst


Durham, North Carolina

2 months ago

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Medical Review Analyst
Durham, North Carolina

2 months ago

Job Description

Title: Medical Review Analyst
Hours : M-F 8 a.m. to 5 p.m. EST.

Duration: 6 months (Possibility of extension based on the needs of the business.)
Location: Remote. Candidates need to be from an approved conversion State; Alabama, Arizona, Arkansas, Colorado, Florida, Georgia, Idaho, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maryland, Michigan, Mississippi, Missouri, North Carolina, Ohio, Oklahoma, Pennsylvania, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, Wisconsin, and Wyoming.
(Training will be 6 weeks.)

Candidates need to have  MS office skills and will be trained in FACETS. 
FACETS experience is a plus but not required.
Coding experience is a plus.

Candidates need to be a team player and have flexibility with working with cases that may need research and are not black and white.  Candidates need to be comfortable working and managing their desk remotely while also working within a team and being a team player.

These roles are production focused with an average of 20 to 30 cases reviewed daily based on complexity.

Job Description:

  • Determines, medical necessity, benefit eligibility and/or appropriate reimbursement allowances for complex claims and/or products by using clinical experience, medical literature, medical records, certificate guidelines, medical policy and several complex and varied computer application software systems. 
  • Ensures that review and determinations meet all requirements per line of business by Regulatory and Accrediting bodies (e.g., federal, state and etc.).
  • Identifies, documents, and escalates system and process problems.  Through analysis, determines root cause and recommends possible solutions.  Defines, communicates and follows up as appropriate on the root causes of errors to others. 
  • Reviews physician-submitted and member-submitted claims for specified services, utilizing professional knowledge and developed criteria, to determine the medical necessity of the treatment.  Refers cases that do not meet criteria to the Medical Director with appropriate clinical analysis and summaries.  Issues denials according to department protocols.  Documents outcome of reviews.
  • Maintains confidentiality of all PHI in compliance with state and federal laws.
  • Recognizes, documents, and reports inappropriate billing patterns or utilization trends of professional and institutional providers to appropriate business owner. Identifies situations in which claims filing/coding guidelines are not being followed by providers; documents examples for referral to Network Management and/or Special Investigations for appropriate action.
  • Communicates with members and providers to obtain additional information.  Informs members, providers, and internal customers of claims status and determinations.  Documents the required clinical information, source and rationale (referencing the appropriate internal and external resources) for decision-making in the appropriate medical management tools.
  • Performs post adjudication review of claims related to coding, billing and reimbursement. (FEP and Senior Market, Medicare HMO/PPO)
  • Reviews claims for Individual Business for possible misrepresentation as needed. Gathers information and prepares documentation for internal review. Takes appropriate action based on internal guidelines.

Hiring Requirements

• RN, PA or NP with a minimum of 3 years previous clinical experience preferably in a variety of clinical settings

• LPN with a minimum of 5 years previous clinical nursing experience preferably in a variety of clinical settings.

• Must hold and maintain a valid North Carolina clinical license.



About Us: Established in 2004, SPECTRAFORCE® is one of the largest and fastest-growing diversity-owned staffing firms in the US. The growth of our company is a direct result of our global client service delivery model that is powered by our state-of-the-art A.I. proprietary talent acquisition platform, robust ISO 9001:2015/ISO 27001 certified processes, and strong and passionate client engaged teams. We have built our business by providing talent and project-based solutions, including Contingent, Permanent, and Statement of Work (SOW) services to over 140 clients in the US, Canada, Puerto Rico, Costa Rica, and India. Key industries that we service include Technology, Financial Services, Life Sciences, Healthcare, Telecom, Retail, Utilities and Transportation. SPECTRAFORCE is built on a concept of “human connection,” defined by our branding attitude of NEWJOBPHORIA®, which is the excitement of bringing joy and freedom to the work lifestyle so our people and clients can reach their highest potential. Learn more at:
Benefits: SPECTRAFORCE offers ACA compliant health benefits as well as dental, vision, accident, critical illness, voluntary life, and hospital indemnity insurances to eligible employees. Additional benefits offered to eligible employees include commuter benefits, 401K plan with matching, and a referral bonus program. SPECTRAFORCE provides unpaid leave as well as paid sick leave when required by law.

Equal Opportunity Employer: SPECTRAFORCE is an equal opportunity employer and does not discriminate against any employee or applicant for employment because of race, religion, color, sex, national origin, age, sexual orientation, gender identity, genetic information, disability or veteran status, or any other category protected by applicable federal, state, or local laws. Please contact Human Resources at if you require reasonable accommodation. 
At SPECTRAFORCE, we are committed to maintaining a workplace that ensures fair compensation and wage transparency in adherence with all applicable state and local laws. This position’s starting pay is: $42.43/hr.