Role Description

The Medical Review Support Analyst supports clinical audit and claims review processes by triaging claims, requesting and managing medical records, and ensuring accurate documentation within claims systems. This role works closely with claims teams and provider networks to gather required records, track claim review status, and ensure compliance with healthcare regulations and organizational standards.

• Perform initial triage of claims selected for review to determine if they meet specific clinical audit criteria.
• Request and obtain medical records from healthcare providers based on review requirements.
• Prepare and send medical record request letters and follow up on outstanding documentation.
• Receive, review, and process medical records received via fax, mail, email, and secure upload systems.
• Research claim history and review pre-authorization determinations when necessary.
• Enter claim processing instructions and documentation into Facets or other claims systems.
• Maintain accurate case notes and required fields in departmental databases.
• Communicate claim review status and documentation updates to claims staff and network management teams.
• Send detailed provider notifications when records are missing or additional documentation is required.
• Maintain production, quality, and compliance standards while adhering to healthcare regulatory requirements.

Qualifications

• High School Diploma or GED.
• 3+ years of experience in a healthcare environment, such as:
  • Medical office
  • Claims processing
  • Medical billing
  • Healthcare customer service
• Strong written and verbal communication skills.
• Experience working with medical records, billing, or healthcare documentation.
• Ability to research issues, analyze information, and resolve problems independently.
• Strong organizational skills with the ability to prioritize tasks and meet deadlines.
• Basic understanding of medical terminology.

Requirements

• Experience using Facets claims system.
• Knowledge of medical coding, anatomy, or healthcare claims processes.
• Familiarity with BlueCard, ITS processes, FEP Direct, or Salesforce.
• Analytical and basic math skills for claims review analysis.