at Department of Healthcare and Family Services in Springfield, Illinois, United States
Job Description
Essential Functions
- Serves as a Prior Approval Reviewer for the Bureau of Professional & Ancillary Services/Prior Approval &
Customer Relations Section/Medical Review Unit - Conducts clinically based research on new technology and medical advancements related to specialized medical
equipment and services and makes recommendations on modifications to current policy and expansion of program
coverage - Conducts clinical analysis of medical procedures and diagnosis coding changes
- Provides expert testimony on behalf of the department, including, but not limited to, fraud and abuse cases and
participant appeals on denials of coverage - Stays abreast of new techniques and procedures in the clinical/medical field
- Performs other duties as required or assigned which are reasonably within the scope of the duties enumerated
above
- Requires an Illinois license to practice medicine
- A minimum of two (2) years of experience making clinical prior approval decisions including, working with complex medical data, and familiarity with medical coding such as ICD-10CM, CPT or HCPCSs
- A minimum of two (2) years of professional experience communicating with medical providers on behalf of a payer
regarding billing codes and rejection codes as well as medical terminology - Requires two (2) years of experience working with Medical Management Information Systems (MMIS) or similar medical processing system
- A minimum of two (2) years of experience making clinical prior approval decisions including, working with complex medical data, and familiarity with medical coding such as ICD-10CM, CPT or HCPCSs
- A minimum of two (2) years of professional experience communicating with medical providers on behalf of a payer regarding billing codes and rejection codes as well as medical terminology
- A minimum of two (2) years of experience working with Medical Management Information Systems (MMIS) or similar medical processing system
- A minimum of two (2) years of experience utilizing the basic principles and practices of general medicine and surgery, including the diagnosis and treatment of diseases and inquiries
- A minimum of two (2) years of experience conducting research regarding recent changes to technology or accepted procedures in the field of general medicine to recommend modifications to policies
- A minimum of two (2) years of experience evaluating the quality of medical care and treatment for a medical or social services organization
- A minimum of two (2) years of experience performing reviews of medical data and determining medical needs for a medical or social service organization
- A minimum of two (2) years of experience preparing detailed and accurate medical documentation to support any medical review determination
- Requires completion of a background check and self-disclosure of criminal history
- Requires the ability to utilize and maintain state issued equipment such as a laptop
- Requires ability to attend seminars, conferences, and trainings to stay current on methods, tools, ideologies, or other industry related topics relevant to the job duties
- The conditions of employment listed here are incorporated and related to any of the job duties as listed in the job
description
