A Medical Reviewer looks into the medical record of patients and checks them to see for any missing documentation. The job description includes checking the physician’s notes to ensure that there is no patient neglect or abuse and verifies that all paperwork is correctly signed. The most common work duties carried out on daily basis are listed on the Medical Reviewer Resume as – finding problems with the record, issuing a citation to the medical staff member if found guilty, ensuring all medical records is up to compliance, reviewing and auditing medical records for completeness and accuracy, and making sure all the documents to be submitted to the insurance carriers are correct and authentic.
To begin with, an associate’s degree of applied science in the Health Information Technology program is needed. However, some of the medical reviewers are registered nurses having training in medical coding. Some useful traits include the following – proficiency in using a computer and relevant software, accuracy, proficiency with medical terminologies, and the ability to adhere to the company’s policies and practices.
Summary : Establishing effective working relationships with people in a wide variety of disciplines and backgrounds; manage and prioritize multiple projects and demands simultaneously; rapidly adjusting to changing priorities and work effectively under pressure.
Skills : Outlook, Planning Skills.
Description :
Managed enrollments within California, reviewed and applied eligibility criteria to membership applications.
Managed caseload of files by researching medical history, utilization, and enrollments.
Ensured all applicants met all membership criteria according to company guidelines.
Met all production and quality control deadlines.
Worked with various regions to resolve issues involving billing.
Medical underwriting, analytical thinking, applied Insurance Medical Underwriting Guidelines to medical applications based upon the information provided.
Researched medications, proficient in HIPAA, PHI, and Confidentiality.
Experience
10+ Years
Level
Senior
Education
MS
Medical Reviewer Resume
Headline : Demonstrating knowledge of relevant FDA, EU, and ICH guidelines, initiatives, and regulations governing both clinical trial and post-marketing safety environments.
Reviewed and applied eligibility criteria to membership applications.
Applied Individual Medical Underwriting Guidelines (IMUG) to the medical applications based upon information provided.
Researched medications, Proficient in HIPAA, PHI, and Confidentiality Typing, billing, enrollments, made telephone calls to prospective members to ensure accuracy.
Utilized programs such as Hestia, Foundations, Intertel Script, and POINT, Microsoft, Excel, Lotus Notes.
Met all production and, quality control guidelines.
Managed caseload of files by researching medical history, utilization and enrollments, within CA.
Trained/facilitated for Labor Management Partnership Modules Interest Based Problem Solving (IBPS), Consensus Decision Making (CDM), and Labor Partnership Orientation.
Experience
5-7 Years
Level
Executive
Education
MS
Medical Reviewer Resume
Headline : Medical Reviewer with 5 years of experience in Reviewing the Adverse event case narrative, coding, product/Indication, labeling in accordance with the respective reference safety documents, causality, and Medical history for medical completeness, accuracy, and overall medical content.
Skills : Planning Skills, Medical Skills.
Description :
Managed incoming calls or incoming post services claims work.
Determined contract and benefit eligibility; provides authorization for inpatient admission, outpatient precertification, prior authorization, and post service requests Refers cases requiring clinical review to a Nurse reviewer Responsible for the identification and data entry of referral requests into the UM system in accordance with the plan certificate.
Responded to telephone and written inquiries from clients, providers, and in-house departments.
Conducted clinical screening process.
Authorized initial set of sessions to the provider.
Checked benefits for facility-based treatment.
Developed and maintained positive customer relations and coordinates with various functions within the company to ensure customer requests and questions are handled appropriately and in a timely manner.
Experience
5-7 Years
Level
Executive
Education
MS
Medical Reviewer Resume
Objective : A Medical Reviewer position in a well-established office to utilize my skills as a hard-working, easy to get along with person in a fast-paced office.
Skills : Abstraction, Microsoft Office, Several Abstraction Tools.
Description :
Reviewed charts for fellow peers.
Maintained above the required productivity and accuracy.
Assisted mgmt in peer training.
Became a Train the Trainer, for the Labor, Management, Partnership.
Trained members and staff in the modules below.
Reviewed Serious Adverse Events (SAEs)/Adverse Events (AEs)/clinical study endpoint events to determine if the events meet pre-defined criteria.
Reviewed Electronic Case Report Forms (eCRFs), medical information, and source documents to develop narratives for the events.
Experience
2-5 Years
Level
Executive
Education
GED
Medical Reviewer Resume
Summary : Over 18 years as a registered nurse (RN) in a variety of health care, clinical research, medical communications, and pharmaceutical settings. Most recently employed in the pharmaceutical industry for over 10 years supporting therapeutic areas of neuroscience, men's and women's health, renal, metabolic, pain, and anesthesia products in a Global Medical Information department role requiring substantial project management, leadership, and medical writing and editing skills.
Skills : Management Experience, Call Center Management, Performance Management.
Description :
Employed as a medical review nurse with Blue Cross/Blue Shield of Montana.
Experienced in working with and implementing current Medical Policies in regards to the appropriate medical care of people who have insurance with this company.
Experienced with current CPT coding and ICD-9 coding as well as the upcoming ICD-10 coding changes.
Experienced in identifying and investigating Medical Fraud.
Able to prioritize the work based on the mandates as defined by the State and Federal governments and the requirements of the company's procedures.
Developed several medical policies and procedures for the department.
Experienced in understanding the benefits of insurance plans and how they pertain to claims and medical procedures themselves.
Experience
10+ Years
Level
Senior
Education
MS
Medical Reviewer Resume
Headline : Analyzing medical data to investigate causes and treatment of toxicity, pathogens, or chronic diseases and adverse event reaction caused due to drugs given for medication, Reviewing and providing PV therapeutic area input for the development of protocols, IBs, SAPs, CSRs, and other relevant project/study documents.
Skills : MS Office, Reviewer.
Description :
Reviewed medical records to determine medical necessity for physical, occupational, and speech therapy, chiropractic care, durable medical equipment, and other requested services.
Determined appropriateness of billing by providers.
Reviewed claims for potential fraud.
Evaluated rate negotiations on large dollar claims.
Audited large dollar claims.
Completed HIAA training for Fraud, levels I & II.
Reviewed and provided determinations of appeals submitted by providers and members.
Experience
5-7 Years
Level
Executive
Education
Master Of Science
Medical Reviewer Resume
Objective : Medical Reviewer professional with fifteen years in medical underwriting, account services, with extensive and technical expertise in the insurance industry. Adept at balancing risk with sales objectives. Possess exceptionally sound judgment and analytical reasoning. Extensive experience in direct sales, electronic medical records, billing, and customer service.
Skills : Insurance, Medical Records, Administrative Support, Data Entry, Medical Billing, Customer Service.
Description :
Managed caseload of files by researching medical history, utilization, and enrollments.
Ensured all applicants met all membership criteria according to company guidelines.
Met all production and quality control deadlines.
Worked with various regions to resolve issues involving billing, utilization, enrollments, and status.
Conducted user testing for new system rollout to minimize defects.
Reviewed and applied eligibility criteria to specific medical conditions and medications.
Reviewed all new applications for completeness and complete all requisite data entry associated with the processing of Individual and small group applications.
Experience
2-5 Years
Level
Executive
Education
AA In Business Management
Medical Reviewer Resume
Headline : Supporting in preparing aggregate safety data reviews for pre-and post-marketing ASRs including Periodic Safety Update Reports (PSURs), Periodic Benefit-Risk Evaluation Reports (PBRERs), Periodic Adverse Drug Experience Reports (PADERs), Development Safety Update Reports (DSLRs), IND annual reports, and other Ad-hoc reports.
Skills : Clinical Trial, Argus, US-FDA, ICH, GCP, MedDRA, Aggregate Reports, MedWatch, CIOMS, Narrative Writing, Sound Medical Knowledge, Medical Review, Signal Detection, Protocol Review, Final Clinical Safety Report.
Description :
Conducted any necessary research including the use of the internet to identify any new or unknown medications listed on applications and report findings to management.
Experienced in process improvement implementation and assisting in the successful transition of improvement strategies into business procedures.
Liaisoned to the Clinical Events Committees (CEC), work with the physicians to facilitate the review and adjudication of SAEs and clinical endpoint events.
Provided MedDRA coding of events, if contracted.
Collaborated with Regulatory Lead, assess adverse events for submission to the client and/or regulatory authorities, if contracted.
Reviewed adjudication results to identify any trends that might become apparent.
Reviewed/QC Study Report Tables that present adjudicated data.
Experience
5-7 Years
Level
Executive
Education
MS
Medical Reviewer Resume
Headline : Liaising with the marketing team(s) to evaluate safety impact and provide input into program design (e.g., social media, market research, patient support programs), and also Assisting in writing and/or reviewing monthly safety signal reports.
Skills : Planning Skills, Developing Skills.
Description :
Performed the role of, or assist with DMC liaison activities, providing the information needed for DMC operation and reporting.
Communicated with SERM Global Safety Leads and Risk Leads regarding cases of special interest or SUSAR reports from clinical trials and provide medical insights on case information.
Provided medical review expertise and guidance on interdepartmental and/or cross-functional initiatives including, process improvement standards development, SOP/MAN creation, and metrics with regards to medical review and case processing.
Supported the development, review, and timely implementation of expected term lists to facilitate expectedness assessments.
Performed individual safety case medical assessments of causality, expectedness, and seriousness of reported clinical trial and post-marketing safety reports in alignment with corporate SOPs.
Contributed to the resolution of issues from cases of high complexity through medical expertise.
Conducted evaluation of other relevant safety information (e.g. from non-clinical studies and product quality complaints) as required.
Experience
5-7 Years
Level
Executive
Education
GED
Medical Reviewer Resume
Headline : Working independently and accepting full responsibility for quality and timeliness of work, Demonstrating trustworthiness and commitment to maintaining confidentiality, the integrity of copyrighted and secure business materials.
Skills : Reviewer, MS Office.
Description :
Approved potential expedited reports to global health authorities from a medical perspective as assigned.
Identified appropriate medical questions/queries to support appropriate safety case follow-up per corporate SOPs.
Created search criteria and prepare Analysis of Similar Events (AOSE).
Contributed to solving reconciliation coding issues/discrepancies.
Supported training to Patient Safety employees on ICSR medical review activities and processes.
Undertook activities delegated by the Qualified Person for Pharmacovigilance (QPPV) as detailed in the Pharmacovigilance (PV) System Master File and maintain a state of inspection readiness.
Served as point of contact for Health Authority Inspection and Internal Process Audits within the remit of role and responsibility.
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