medical-reviewer

“In everything we do, we set the highest standards for quality and competence on every project. As a result, our actions become the benchmark for our industry but also our own guiding principle, which we renew every day”.

DQS sets the highest standards of expertise, experience, and quality for its customers. DQS core competencies lie in the performance of certification audits and assessments. This makes DQS, headquartered in Frankfurt am Main/Germany with an annual turnover of 136 Mio EUR (in 2020) one of the leading providers worldwide with the claim to set new benchmarks in reliability, quality, and customer orientation at all times. Over 2,500 highly qualified and experienced auditors carry out over 125,000 customer-specific audits according to over 200 recognized norms and standards in more than 60 countries every year. 

DQS was founded more than 35 years ago by the German Society for Quality (DGQ), the German Institute for Standardization (DIN) and other German industry associations with the claim to perform certifications and audits for organizations worldwide at the highest level. With its foundation, DQS was the first independent certification service provider in Germany. In 2008, the U.S. organization Underwriters Laboratories brought its international management system certification business into the group as a further shareholder, thus enabling the group to take a major step towards a global presence.

• fachliche Prüfung und Bewertung von Bewertungen und Gutachten zu Medizinprodukten im Rahmen der geltenden regulatorischen Anforderungen gemäß MDR (EU-Verordnung 2017/745)
• mit Kolleginnen und Kollegen aus verschiedenen Fachbereichen zusammenarbeiten, um sicherzustellen, dass die Bewertungen medizinisch fundiert, nachvollziehbar und regelkonform sind
• feststellen, wann ein Fachbeitrag zur Beurteilung der vom Hersteller durchgeführten klinischen Bewertung erforderlich ist, und entsprechend qualifizierte klinische Experten benennen
• Schulung der externen klinischen Sachverständigen in den Anforderungen der Verordnung (EU) 2017/745, Leitlinien und Normen sowie Sicherstellen ihres Bewusstseins über Bedeutung und Auswirkungen ihrer Bewertungen und Empfehlungen
• Überprüfung der Vergleichbarkeit und Konsistenz der Bewertungen der klinischen Sachverständigen
• Bewertung der klinischen Bewertung des Herstellers und des Gutachtens externer Sachverständiger sowie Abgabe einer Empfehlung für die Zertifizierungsentscheidung
• Durchführung der klinischen Bewertung und Erstellung des Bewertungsberichts (CEAR)

Interner Kliniker, Clinical Reviewer

Clinical Reviewer assessing medical product evaluations under MDR regulations. Collaborating with experts to ensure compliance and quality in assessments.

Christian Care Ministry is an organization that offers a healthcare sharing program called Medi-Share, which is an affordable and faith-based alternative to traditional health insurance. Through this ministry, members share each other’s medical expenses and offer mutual support through prayer during medical challenges. Medi-Share is not classified as insurance but as a not-for-profit ministry exempt from insurance regulation, providing a community-driven healthcare solution. It operates nationwide and promotes a Biblical approach to healthcare cost-sharing.

Christian Care Ministry (CCM) is a non-profit that administers Medi-Share, a healthcare sharing program where Christians come together to share each other’s medical bills. CCM employs more than 700 individuals in Melbourne, FL, Colorado Springs, CO and remotely throughout the United States.

Christian Care Ministry

• Works with leadership, clinical staff, key internal departments, and external customers to ensure optimum clinical outcomes for members
• Organizes, reviews, and interprets members’ medical records and compares them against proprietary program guidelines, CMS and FDA approved policies, and evidenced-based clinical criteria as appropriate to determine eligibility for bill sharing and advocacy for additional programs and interventions; determines if the medical record documentation supports the eligibility of requested and/or billed services
• Completes medical review casework as assigned and meets SLAs
• Abstracts review-related data/information accurately and timely in appropriate IT systems.
• Provides accurate and timely submission of all administrative and review-related documents to appropriate parties
• Provides appropriate consultation and referral to intra- and interdepartmental resources to ensure members receive optimum services offered by organization
• Makes case presentations to medical leadership for assistance in making sharing determinations
• Manages assigned clinical caseload meeting SLAs
• Delivers accurate and clear verbal and written communication to internal and external customers while complying with organizational HIPAA requirements
• Maintains accurate and timely records of all communications and interventions
• Performs ongoing process improvement for efficiencies and effectiveness
• Performs administrative and clinical processes to ensure team and departmental goals are met
• Contributes to the exercise and expression of Christian Care Ministry’s Christian beliefs
• All other duties as assigned

Clinical Reviewer II – LPN

Clinical Reviewer II at Christian Care Ministry assessing medical records for healthcare sharing eligibility. Collaborating with clinical staff to ensure optimal outcomes in a faith-based organization.

Simsy Ventures is a venture builder and institutional co-founder that partners with entrepreneurs, investors, and corporations to create sustainable startups. Their mission focuses on enabling startups to achieve true potential while promoting a positive impact on profits, people, and the planet. With a structured approach, they support startups throughout their lifecycle, from ideation to market validation and growth. By leveraging a repeatable venture studio model, Simsy Ventures aims to uplift economies globally through impactful entrepreneurship.

Simsy Ventures is a venture builder, an institutional co-founder, and a partner for entrepreneurs (co-founders), investors, corporations, and the global startup ecosystem.

We forge partnerships to collaborate and co-create fast-growing sustainable startups that become purpose-driven impactful companies - from idea generation, market validation, sustainability mapping, product-market fit, traction & unit economics, growth hacking, and launching new ventures to providing ongoing support.

Our shared mission is to enable sustainable startups with a sustainability mindset to have a net positive impact on profits, people & the planet earth.

1. Investors: Invest with us 💰
2. Co-founders: Build with us 🪴
3. Corporates: Innovate with us 💡
4. Startup Ecosystem: Grows with us 📈
5. Associates: Build their dream with us 🚀

Most importantly, We’re Hiring Venture Builders! 📢

Simsy Ventures

• Performs medical claim reviews for one or more of the following: claims for medically complex services, services that require preauthorization/predetermination, requests for appeal or reconsideration, referrals for potential fraud and/or abuse, and correct coding for claims/operations.
• Makes reasonable charge payment determinations based on clinical/medical information and established criteria/protocol sets or clinical guidelines.
• Determines medical necessity and appropriateness and/or reasonableness and necessity for coverage and reimbursement.
• Documents medical rationale to justify payment or denial of services and/or supplies.
• Educates internal/external staff regarding medical reviews, medical terminology, coverage determinations, coding procedures, etc. in accordance with contractor guidelines.
• Participates in quality control activities in support of the corporate and team-based objectives.
• Provides guidance, direction, and input as needed to LPN team members.
• Provides education to non-medical staff through discussions, team meetings, classroom participation and feedback.
• Assists with special projects and specialty duties/responsibilities as assigned by Management.
• Full time (40 hours/week) Monday-Friday, 8:00 am – 4:30 pm.
• Work-from-home position; remote within three hour driving radius of Augusta, GA 30909.

Medical Claims Reviewer

RN Medical Claims Reviewer at Broadway Ventures conducting pre- and post-pay reviews, determining medical necessity and coding for Medicare claims for Palmetto GBA.

• Conduct medical claim reviews for Durable Medical Equipment (DME) claims including complex services, pre-authorizations, appeals, fraud investigations, and coding accuracy
• Use established clinical guidelines and protocol sets to make coverage and reimbursement determinations
• Ensure claims meet contractor standards and comply with Medicare guidelines
• Document medical rationale for claim approvals or denials
• Provide education and support to internal/external teams regarding medical reviews, coverage determinations, and coding procedures
• Participate in quality control activities and support LPN team members
• Assist with special projects and additional responsibilities as assigned

Remote Registered Nurse reviewing DME Medicare claims for Broadway Ventures, determining medical necessity and ensuring compliance.

Hybrid Medical Reviewers Jobs