Case Reviewer

Integrated Management Strategies, LLC

12h • Remote

About The Position

Integrated Management Strategies (IMS) is seeking an experienced Case Reviewer to join their healthcare consulting practice. The role is fully remote within the US, with quarterly travel to Columbia, MD for training. As a Case Reviewer, you will play a critical role in the Utilization Management department, responsible for performing utilization review and medical management of prior authorizations for plans of service. This position requires a meticulous approach to evaluating medical necessity, appropriateness, and efficiency of healthcare services, procedures, and settings under the provisions of each patient’s benefits.

Requirements

• Bachelors degree in related field
• Commitment to staying current with changes in medical guidelines, policies, and regulations
• Willingness to participate in ongoing education and training
• Experience or interest in participating in quality improvement initiatives
• Ability to work effectively with a diverse patient population and colleagues
• Strong organizational skills and ability to manage multiple tasks and priorities

Nice To Haves

• Prior Utilization Management knowledge preferred
• Familiarity with Home and Community Based Services (HCBS) waiver programs is a plus
• Durable Medical Equipment (DME) knowledge is a plus
• Good written and oral communication skills are required
• Typing and data entry skills, familiarity with computer systems, and use of multiple monitor work systems

Responsibilities

• Conduct thorough reviews of prior authorization requests to determine medical necessity and compliance with established guidelines and criteria
• Assess and manage the appropriateness of healthcare services, ensuring they align with evidence-based practices and organizational policies
• Work closely with participant supports, and internal teams to facilitate effective communication and resolution of authorization requests
• Maintain accurate and detailed records of all reviews and decisions, ensuring compliance with regulatory requirements and organizational standards
• Stay current with changes in medical guidelines, policies, and regulations.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level