Medical Review Analyst II at Elevance Health in Roanoke, Virginia

Posted in Other 11 days ago.





Job Description:

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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