Clinical Reviewer

This role utilizes clinical expertise to review medical documentation, ensuring medical necessity and appropriate levels of care through MCG/InterQual, state/federal guidelines, and billing regulations. The position validates medical records and claims to support correct coding and appropriate provider reimbursement. It involves facilitating clinical reviews for prior authorization appeals, claim audits, and complex case evaluations. The role also serves as a clinical resource for utilization management and supports quality of care initiatives.