Medical Review Specialist

20910, Silver Spring
Mar 08, 2019
Mar 21, 2019
Administrative, Other
Full Time

Job Summary/Company:

A reputable, privately held insurance and financial services company is seeking a Medical Review Specialist to join their well-established team! If you have an RN Licensure and are looking to work in a Case Management setting-we’d love to chat with you!


  • Obtain and review claims information, including large claim and trigger diagnosis reports along with case management and clinical narratives notes on current and prospective stop loss clients.  Estimate future costs of known ongoing medical conditions for the next policy period. Communicate these cost projection recommendations to underwriting staff.
  • Review the medical necessity and appropriateness of hospital claims, physician charges, specialty drug costs, usage and provide recommendation.
  • Gather and analyze clinical information and medical records from plan &/or their administrators for cost containment and future cost determination;  Maintain a close working relationship with plan administrators, vendors, third party payers, employers and re-insurers.
  • Apply clinical knowledge to make determinations on medical necessity. Troubleshoot complex clinical problems and practice independently without supervision of another licensed professional.    
  • Assess medical needs, care requirements and alternatives; monitor and follow up with the Plan Administrator, Plan’s case management vendors, etc. regarding the planning, coordination and progress of treatment; evaluate and recommend alternative treatments/facility, as necessary to facilitate quality, cost-effective medical care for high risk individuals, trigger diagnoses and transplant losses.       
  • Provide cost containment initiatives by managing an inventory of Stop Loss claims (involving large case management, trigger diagnosis or transplant network losses).
  • Prepare monthly report on all large case management. Communicate daily regarding large cases to the appropriate individuals.

Qualifications/Background profile:

  • Bachelor’s Degree
  • 3-5 years of experience as a health professional with an RN Licensure
  • Knowledge of HIPAA Regulations
  • Hands on experience with PC; Word, Excel
  • Strong Customer Service skills with all levels of personnel

Qualified candidates should send their resume AND call Sparks Group for additional details. Please note, resume must include a valid email address in order to be considered. We look forward to discussing your background, your current job search, and your potential career path with Sparks Group!

Sparks Group is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, age, pregnancy, citizenship, family status, genetic information, disability, or protect veteran status.

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