Position: Medical Claims Review Specialist

Location: Columbia SC

Duration :3+ months

Pay Rate: $24/hr on W2

We are looking for a Medical Claims Review Specialist to join one of our Fortune 500 Healthcare clients.

Job Description :

The Medical Claims Review Specialist is responsible for evaluating medical claims and performing utilization management to ensure services meet established guidelines and criteria. This role involves a thorough review of inpatient and outpatient services, documenting all decisions and providing support for medical claims. The specialist must also communicate effectively with members, providers, and other team members regarding coverage and eligibility, while ensuring compliance with guidelines and protocols.

Key Responsibilities:

Medical and Utilization Review (80%) :

• Conduct medical reviews using established criteria and clinical guidelines.

• Evaluate professional, inpatient, outpatient, and facility services for medical necessity and benefit coverage.

• Document decisions accurately, following protocol sets or clinical guidelines.

• Review and approve or deny medical claims, ensuring appropriate payment determination.

• Monitor timeliness of review processes and ensure compliance with contractor standards.

• Perform the authorization process, verifying coverage for medical services within benefit and medical necessity guidelines.

• Utilize resources to support review determinations and conduct high-dollar forecasting research.

• Summarize patient health status, project future medical costs, and assess risk through screenings/telephone assessments.

• Review first-level appeals with thorough documentation of determinations and decision rationale.

Education and Communication (10%) :

• Educate internal and external staff on medical review protocols, coverage determinations, and coding procedures in line with contractor guidelines.

• Respond accurately and promptly to members and providers, providing documentation on rendered determinations.

Quality Control and Training (10%) :

• Participate in quality control initiatives to support team and corporate objectives.

• Engage in all required training to ensure up-to-date knowledge of industry standards and company protocols.

Qualifications:

• Clinical experience in a healthcare setting or related field (e.g., nursing, medical coding, claims review).

• Knowledge of medical terminology, claims processing, and utilization review protocols.

• Strong documentation and communication skills to support determination explanations and member/provider interactions.

• Familiarity with coding procedures, coverage guidelines, and regulatory standards.

• Ability to perform detailed analyses and project patient health outcomes and associated costs.

We are looking for the candidate who are eligible to work with any employers without sponsorship .

If you’re interested, please click “Apply” button.

If you are not available or this job is not a good fit at present, please share the job details with your friends/colleagues and let me know if anyone is interested.

ManpowerGroup is committed to providing equal employment opportunities in a professional, high quality work environment. It is the policy of ManpowerGroup and all of its subsidiaries to recruit, train, promote, transfer, pay and take all employment actions without regard to an employee's race, color, national origin, ancestry, sex, sexual orientation, gender identity, genetic information, religion, age, disability, protected veteran status, or any other basis protected by applicable law.