A Medical Review Specialist is hired to provide quality assurance to patients within the medical facility. The most common work activities associated with the role are listed on the Medical Review Specialist Resume as performing quality control related to patient treatment, interviewing patients and their family members, ensuring staff is properly provided to patients, reporting to designated managers in case of reportable conditions or critical incidents, modifying patient care plans after reviewing medical chart and history, auditing patient records, and investigating questionable claims.
Those seeking this job role should be able to mention on the resume the following skills – the ability to follow the privacy laws of the patients, keeping updated with the latest happenings, the ability to mentor juniors, record management skills, and proficiency in using relevant software. A bachelor’s degree in fields such as health care management, or a related field is acceptable. Sometimes a substantial amount of experience is preferred in lieu of a degree.
Objective : Dedicated Medical Review Specialist with two years of experience in evaluating clinical documentation and ensuring compliance with healthcare regulations. Proven ability to collaborate with healthcare providers to streamline processes and enhance patient outcomes. Committed to leveraging analytical skills to support medical necessity determinations and improve claims processing efficiency.
Skills : Data Entry And Management, Data Analysis And Reporting, Clinical Documentation Review, Claims Processing And Appeals
Description :
Reviewed clinical documentation to assess compliance with Medicare criteria for Durable Medical Equipment.
Communicated effectively with healthcare professionals to gather necessary information for claim processing.
Verified eligibility and benefits for Medicare and private insurance, ensuring accurate claim submissions.
Processed pre-authorizations and pre-certifications to expedite patient access to medical services.
Coordinated with sales representatives to ensure timely delivery of medical equipment and services.
Utilized RightFax to manage incoming faxes and maintain accurate records.
Analyzed data to identify trends in claims processing and improve operational efficiencies.
Experience
0-2 Years
Level
Entry Level
Education
B.S. in HA
Clinical Review Specialist Resume
Objective : Accomplished Clinical Review Specialist with 5 years of experience in analyzing clinical documentation and ensuring adherence to healthcare regulations. Skilled in collaborating with multidisciplinary teams to enhance patient care and optimize claims processing. Eager to apply analytical expertise to support effective medical necessity evaluations and improve operational efficiencies.
Skills : Pharmacovigilance, Clinical Trials, Medical Coding, Risk Assessment, Protocol Development
Description :
Conduct thorough reviews of medical records for accuracy and compliance.
Conducted thorough medical reviews of claims, ensuring accuracy and timeliness.
Reviewed customer service inquiries regarding claims, providing accurate and timely responses.
Executed special projects aimed at improving clinical review processes.
Determined benefit availability based on company contracts and medical policies.
Verified member eligibility prior to conducting medical reviews.
Fostered collaborative relationships across departments within BCBSNE to enhance operational efficiency.
Experience
2-5 Years
Level
Junior
Education
BSN
Medical Review Specialist Resume
Headline : Experienced Medical Review Specialist with 7 years of expertise in evaluating clinical documentation and ensuring regulatory compliance. Adept at collaborating with healthcare teams to optimize patient care and streamline claims processing. Passionate about applying analytical skills to enhance medical necessity assessments and drive operational improvements.
Skills : Windows Operating Systems, Microsoft Office Suite (excel, Word, Powerpoint), Pharmaceutical Claims Analysis, Healthcare Management Software, Electronic Health Record Systems, Clinical Guidelines
Description :
Reviewed and analyzed high-dollar medical claims to identify discrepancies and assess compliance with billing guidelines.
Documented audit findings and generated comprehensive reports, adhering to quality assurance standards.
Communicated effectively with healthcare providers to validate treatment plans and confirm service eligibility.
Utilized databases to identify and evaluate approved mental health agencies for service provision.
Maintained detailed records of medical facility communications and transcribed data into electronic systems.
Demonstrated self-motivation by managing a high volume of claims independently while meeting tight deadlines.
Generated reports tracking statistics for internal and external reviews, ensuring accurate data reporting.
Experience
5-7 Years
Level
Senior
Education
B.S. Health Admin.
Senior Medical Review Specialist Resume
Summary : With a decade of experience as a Senior Medical Review Specialist, I excel in evaluating clinical documentation and ensuring compliance with healthcare regulations. My expertise lies in collaborating with healthcare teams to enhance patient outcomes and optimize claims processing. I leverage analytical skills to support medical necessity determinations and drive operational efficiencies.
Skills : Microsoft Word, Microsoft Excel, Microsoft Access, Typing Speed 45 Wpm, Data Management, Clinical Research
Description :
Evaluated and processed MERC Physical Therapy claims, ensuring adherence to regulations.
Utilized Microsoft Excel to maintain detailed records of physical therapy claims payments.
Communicated daily with Blue Cross Blue Shield regarding Pre-Certification requests.
Managed customer inquiries from healthcare professionals and members regarding coverage changes.
Resolved member and provider complaints related to service approvals and denials.
Assisted with walk-in inquiries and coordinated communication with pharmacies.
Ensured timely and accurate payment of medical, DME, and prescription claims.
Experience
7-10 Years
Level
Management
Education
BSHA
Medical Review Specialist Resume
Summary : Skilled Medical Review Specialist with 10 years of experience in assessing clinical documentation to ensure compliance and enhance patient care. Proven expertise in collaborating with healthcare teams to streamline processes and improve claims accuracy. Dedicated to utilizing analytical capabilities to support medical necessity evaluations and drive operational improvements.
Skills : Medical Documentation Software, Health Care Regulations, Ethics In Research, Project Management, Team Collaboration, Critical Thinking
Description :
Analyzed clinical documentation to ensure compliance with healthcare regulations and standards.
Collaborated with healthcare providers to enhance patient outcomes and streamline admissions processes.
Educated patients and families on treatment plans and medical care protocols.
Managed referrals for complex cases to medical case management for further support.
Provided training and orientation for new staff on compliance and documentation practices.
Organized and maintained accurate coding for all medical submissions to ensure proper database entry.
Conducted audits of medical documents to identify areas for improvement in claims processing.
Experience
10+ Years
Level
Executive
Education
BSN
Lead Medical Review Specialist Resume
Summary : As a Lead Medical Review Specialist with 10 years of extensive experience, I excel in evaluating clinical documentation for regulatory compliance. My background includes collaborating with healthcare teams to enhance patient care and optimize claims processing. I am driven to utilize my analytical skills to support medical necessity assessments and streamline operational workflows.
Skills : Regulatory Compliance, Healthcare Compliance, Medical Necessity Evaluation, Medical Device Knowledge
Description :
Managed appeals for inpatient services, ensuring thorough review for medical necessity and level of care.
Responded to inquiries from facilities and physicians regarding appeal status, fostering effective communication.
Coordinated the flow of medical records and correspondence to support timely medical appeals.
Processed appeals accurately within departmental and corporate guidelines, maintaining compliance.
Integrated clinical rationale into appeal documentation, adhering to established timelines.
Followed up on medical record requests, ensuring all necessary documentation was obtained.
Trained team members on best practices for appeal processing and regulatory compliance.
Experience
7-10 Years
Level
Management
Education
BSN
Medical Review Specialist Resume
Objective : Detail-oriented Medical Review Specialist with over 5 years of experience in evaluating clinical data and ensuring compliance with regulatory standards. Proven ability to analyze complex medical information and provide accurate assessments. Strong communication skills facilitate collaboration with healthcare professionals and stakeholders to enhance patient care and safety.
Skills : Effective Communication Skills, Communication Skills, Attention To Detail, Medical Terminology, Statistical Analysis, Problem Solving
Description :
Conducted thorough reviews of clinical documentation to ensure compliance with healthcare regulations.
Collaborated with medical offices to verify information and enhance the accuracy of medical record reviews.
Identified and resolved documentation deficiencies, leading to improved compliance outcomes.
Participated in quarterly strategy meetings to discuss budget, operational improvements, and service delivery.
Managed administrative projects, focusing on data management and process enhancements.
Provided exceptional customer service, receiving accolades for handling inquiries from Fortune 500 clients.
Experience
2-5 Years
Level
Executive
Education
B.S. Health Admin.
Medical Claims Reviewer Resume
Headline : Dynamic and detail-oriented Medical Claims Reviewer with 7 years of specialized experience in assessing and validating medical claims for accuracy and compliance. Expertise in collaborating with healthcare providers to optimize claims processing and enhance patient care. Committed to leveraging analytical skills to improve operational efficiencies and support effective medical necessity evaluations.
Skills : Technical Writing, Data Interpretation, Health Economics, Biostatistics, Quality Control, Regulatory Submissions
Description :
Evaluated and validated complex medical claims to ensure compliance with regulatory standards and company policies.
Collaborated with healthcare providers to gather necessary documentation and resolve discrepancies in claims.
Utilized analytical skills to assess medical necessity and appropriateness of services rendered.
Maintained up-to-date knowledge of healthcare regulations impacting claims processing.
Conducted quality assurance reviews, identifying areas for process improvement.
Engaged in training sessions to enhance the skills of team members in claims analysis.
Generated reports on claims processing metrics to inform management decisions.
Experience
5-7 Years
Level
Management
Education
B.S. Health Admin.
Medical Review Specialist Resume
Objective : Proficient Medical Review Specialist with 5 years of experience in assessing clinical documentation for compliance with healthcare regulations. Adept at collaborating with healthcare professionals to enhance patient care and optimize claims processing. Driven to apply analytical skills towards effective medical necessity determinations and improve operational workflows.
Skills : Patient Safety, Adverse Event Reporting, Literature Review, Data Analysis, Medical Writing, Quality Assurance
Description :
Edited and revised clinical documentation to ensure compliance with AMA style and client specifications.
Reviewed and interpreted scientific documents to create concise, medically accurate communications.
Coordinated editing processes to align with client expectations and regulatory standards.
Ensured accuracy of scientific writings and data for client compliance.
Utilized reference management software to maintain accurate documentation.
Represented the organization professionally, enhancing client relationships.
Conducted compliance audits to ensure adherence to regulatory requirements.
Experience
2-5 Years
Level
Executive
Education
B.S. Health Sci.
Medical Review Specialist Resume
Objective : Experienced Medical Review Specialist skilled in conducting thorough reviews of clinical trials and medical records. Adept at identifying discrepancies and ensuring adherence to protocols and regulations. Excellent analytical skills combined with a strong understanding of medical terminology and healthcare regulations, contributing to improved patient outcomes and safety.
Skills : Database Management, Clinical Documentation, Patient Advocacy, Health Policy, Evidence-based Medicine
Description :
Developed and implemented Standard Operating Procedures (SOPs) to ensure compliance with quality standards.
Conducted thorough reviews of clinical documentation to ensure adherence to Good Manufacturing Practices (GMPs) and Good Laboratory Practices (GLPs).
Reviewed and analyzed quality control data for compliance and product integrity.
Collaborated with operational teams to enforce compliance through routine inspections and audits.
Contributed to the writing of annual product reviews and training programs focused on quality assurance.
Coordinated investigations and corrective actions related to product quality issues.
Worked autonomously with minimal supervision while effectively managing new assignments.
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