Clinical Reviewer

The Clinical Reviewer serves as a subject matter expert in the clinical review of claims, claim disputes, appeals, and FWA special investigations. This role involves reviewing facility claims to determine medical necessity and coverage, utilizing clinical guidelines, and presenting cases to the Medical Director. The position requires resolving prior authorization issues, conducting FWA investigations, and maintaining strict confidentiality and documentation standards. The ideal candidate will have extensive experience in clinical review within a Medicare Advantage or managed healthcare environment.