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.
Headline : To obtain a part-time Medical Review Specialist position with an emphasis on Sales Support/Office Management utilizing extensive experience and skills. Productive in contributing effectively towards the objectives of a team, and is able to share knowledge, ideas and information.
Skills : Medical Review, Typing 60 WPM, 10 Key, Medical Coding, Medical Billing, Customer Service, Nursing Assistant training, Resident Care.
Description :
Reviewed physicians clinical notes to determine if our patient's meet Medicare's criteria for Durable Medical equipment.
Corresponded with physicians, nurses and medical assistants to obtain the necessary medical information for completing the process of a claim.
Verified Medicare and Private insurance benefits and eligibility.
Submitted claims for pre-authorization or pre-certification.
Verified co-pay and hardships (If applicable).
Coordinated delivery with the appropriate sale representatives and processing of paperwork.
Retrieved faxes and logging faxes into Rightfax.
Experience
5-7 Years
Level
Executive
Education
GED
Medical Review Specialist Resume
Objective : As a Medical Review Specialist, responsible for Collaborating with the Integrity team to design and implement strategies to detect spam, phishing, malware, fraud, etc, and also Reporting on trends, advocating for platform level solutions to common issues and highlighting up-and-coming titles.
Skills : Excel, InterQual.
Description :
Responsible for meeting all State and Federal regulations as well as BCBSA and BCBSNE mandates related to claims processing.
Responsible for accurate and timely medical review of claims.
Responsible for accurate and timely medical review of Customer Service inquiries about claims.
Responsible for completion of special projects.
Responsible for determining availability of benefits according to company contracts, endorsements and medical policy.
Responsible for determining member eligibility prior to medical review.
Responsible for fostering a constructive relationship with all departments within BCBSNE.
Experience
0-2 Years
Level
Entry Level
Education
Bachelor Of Science In Nursing
Medical Review Specialist Resume
Headline : Seeking a professional mid-level business position where there is room for advancement. I feel confident that my education, support skills, and a high degree of motivation qualify me to be considered for a managerial position. As the enclosed resume further details, my background includes Customer Service, Health Care/Benefits Administration, and Call Center Experience.
Skills : Windows 2000, Windows XP, Windows ME, Microsoft Office Suite, RxNavigator, PeopleSoft, Epic, Centricity Enterprise, Oracle - LMS.
Description :
Responsible for reviewing and analyzing high dollar medical claims to identify errors, fraud, and determine if care provided corresponds to the charges submitted.
Responsible for documenting audit results and creating audit reports within time and quality assurance standards.
Communicated with medical providers and Department of Health Family Services (HFS) to determine if the primary diagnosis, treatment plan and time requested is an approvable Medicaid service.
Reviewed database and lists in order to identify approvable mental health agencies.
Documented thoroughly and completely information that is provided from medical facility and transcribed into adept database.
Position required self motivated individual who can complete a high volume of work independently.
Accesses and prints reports, tracks statistics for daily internal reporting and weekly reporting to HFS.
Experience
5-7 Years
Level
Executive
Education
Bachelor Of Arts
Medical Review Specialist Resume
Summary : A skilled individual with proven ability to organize and motivate associate in a multi task environment. An energetic self-starter with an extensive background in customer service and human resources.
Skills : Ms Word, MS Office, Medical Terminology, Ms Excel, Ms Access, Type 45 Wpm, Data Entry, Customer Service.
Description :
Reviewed and paid MERC Physical Therapy claims received.
Maintained amounts paid concerning physical therapy claims on Microsoft Excel Spreadsheet.
Maintained contact with Blue Cross Blue Shield of Tennessee concerning Pre-Certification requests on a daily basis.
Handled Customer service calls from Doctors and members concerning changes in Plan coverage.
Handled all Member and Provider complaints concerning services approved, needed or denied.
Handled all walk-in questions Set up and make telephone calls concerning any inquiries from Pharmacies.
Assisted in making sure that all medical, DME and prescription claims are paid promptly and correctly.
Experience
10+ Years
Level
Senior
Education
MS
Medical Review Specialist Resume
Headline : As a Medical Review Specialist, responsible for Providing analytical, planning, and oversight for a variety of software programs, Playing a significant role in business process re-engineering of administrative programs to integrate existing and new software applications.
Skills : MS Office, Claims Specialist.
Description :
Received telephone notification of hospital admission.
Communicated with hospital and doctor's offices on patient's condition, treatment plans to improve admissions and reduce length of hospital stay.
Educated patients and families regarding medical care.
Referred long term cases to medical case management.
Provided orientation for new staff.
Educated staff on time management, multiple traumas and head injuries.
Organized and coded all documents related to medical submissions from physicians and/or enrollee to be entered in the Medicare computer database.
Experience
5-7 Years
Level
Executive
Education
Bachelor's
Medical Review Specialist Resume
Headline : Responsible for Serving as subject matter expert on VistA packages, Managing user access to software programs, and also Analyzing, testing, and evaluating new software packages.
Skills : Home health care, Patient care, Assessment, Patient education.
Description :
Responsible for handling appeals for inpatient services that has been denied as not medically necessary or level of care denied.
Accurately responded to frequent calls from facilities, appeal agencies, and physicians on status of the appeal.
Coordinated the flow of medical records and all written correspondence for the medical appeals.
Processed all appeals in a timely and accurate manner.
Added clinical rationale information to appeal guidelines of 23 days and cooperated standard guidelines of 30 days.
Processed and closed all level 2 appeals within departmental guidelines of 53 days and corporate standard guidelines of 60 days.
Followed up on the status of medical record requests with business sites.
Experience
5-7 Years
Level
Executive
Education
Associates Of Science
Medical Review Specialist Resume
Summary : To establish a long-term career in a company where I may utilize my Medical Review Specialist professional skills and knowledge to be an effective Associate Program Manager and inspiration to those around me.
Skills : Strong Verbal And Personal Communication, Accuracy.
Description :
Placed calls to medical offices to verify location information for medical record reviewers.
Conducted confirmation calls for upcoming review appointments.
Reviewed and provided comments on the adequacy of the document s and took necessary steps to cure any deficiencies.
Verified all information in database was up to date and accurate.
Attended quarterly meetings concerning budget, price increases and state of the company Plan, coordinate community service events for the Department Lift truck Operator.
Worked on various administrative projects as assigned including benefit calculations, data management and process improvement.
Handled incoming calls from our Fortune 500 clients, received outstanding customer service awards.
Experience
7-10 Years
Level
Management
Education
High School Diploma
Medical Review Specialist Resume
Objective : Responsible for Preparing and implementing HAS contingency plans for system failure, Monitoring, evaluating and correcting errors for all daily workload transmission.
Knowledged of Lotus notes, Word, AS400, basic Excel, and ACD Accomplishments: Received awards for the highest approvals rates.
Responsible for maintaining professional licensure.
Responsible for referrals to other areas of the corporation to ensure appropriate resource utilization within the company.
Maintained and followed current editorial and style guidelines.
Attended planning meetings with internal team members to determine specifications and timelines for individual projects.
Conducted literature searches of relevant material.
Assisted in the research and scientific content development for proposals.
Experience
2-5 Years
Level
Executive
Education
High School Diploma
Medical Review Specialist Resume
Objective : Responsible for Designing workflows to support escalations from tier-one review staff and other improvements to internal tools and processes, and also Driving developer education and awareness to deliver a best-in-class experience.
Skills : Delivering Skills, Coordinating Skills.
Description :
Edited and altered custom communications in AMA style to agreed specifications and to budgeted timelines to meet client requirements.
Reviewed and interpreted scientific / technical documents and process information into concise and medically accurate scientific communications.
Coordinated editing and revisions to clients expectations and for style.
Reviewed scientific writings and data to ensure medically accurate information to client specifications.
Experienced with reference manager software.
Represented the company in a professional manner through appropriate demeanor, behavior and dress.
Performed a wide variety of activities to ensure compliance with applicable regulatory requirements.
Experience
2-5 Years
Level
Executive
Education
MS
Medical Review Specialist Resume
Objective : Seeking a Medical Review Specialist profession with an outstanding career opportunity that will offer a rewarding work environment along with a winning team that will fully utilize management skills.
Skills : Training Skills, Control Management.
Description :
Participated in developing Standard Operating Procedures (SOPs) to ensure quality objectives are met.
Maintained routine programs and processes to ensure high quality products and compliance with current Good Manufacturing Practices (GMPs) and Good Laboratory Practices GLPs).
Reviewed manufacturing, deviations, change controls, environmental monitoring and quality control data for in-process and finished products.
Worked directly with operating entities to ensure that inspections, statistical process control analyses and audits are conducted on a continuing basis as specified to enforce requirements and meet specifications.
May participated in the writing of annual product reviews and the development of training programs regarding all aspects of producing quality products.
May conducted or served as a lead/coordinator of investigations and corrective and preventive action (CAPA) recommendations related to manufactured products.
Normally received very little instruction on routine work, general instructions on new assignments.
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