Job Description

This role focuses on validating documentation completeness, consistency, and alignment with payer requirements. The position requires strong attention to detail, the ability to interpret clinical documentation in a non-clinical capacity, and clear communication with internal teams regarding documentation findings. The role follows established guidelines, documented criteria, standard operating procedures, and supervisory direction while supporting accurate, timely, and consistent documentation review.

Core Competencies

• Medical Documentation Review - Reviews and interprets medical records, claims documentation, and supporting clinical information in a non-clinical capacity.

• Payer Criteria & Medical Necessity - Applies established insurance medical necessity criteria, payer requirements, internal review standards, and workflow instructions consistently.

• Documentation Accuracy & Quality - Identifies missing, incomplete, inconsistent, or unclear documentation while maintaining strong attention to detail and quality expectations.

• Written Communication - Prepares clear, concise, and professional summaries of documentation findings, including specific references to missing or supporting information.

• Process & Compliance Discipline - Follows established criteria, checklists, standard operating procedures, privacy requirements, and escalation pathways.

• Organization & Productivity - Manages multiple cases and competing priorities while meeting established timelines, productivity standards, and accuracy expectations.

Essential Duties & Responsibilities

• Review medical records, claims documentation, payer criteria, and related support materials to determine whether documentation appears complete and consistent with stated medical necessity requirements.

• Compare submitted documentation against established insurance medical necessity criteria, internal review standards, and workflow instructions.

• Identify missing, incomplete, inconsistent, or unclear documentation and communicate findings to the appropriate internal team members.

• Document review outcomes accurately and consistently in designated systems, trackers, or case management tools.

• Prepare clear written summaries of documentation findings, including specific references to missing or supporting information.

• Maintain confidentiality of patient, provider, and claims information in accordance with company policies and applicable privacy standards.

• Follow established escalation pathways when additional review, clarification, or supervisor guidance is required.

• Meet defined productivity, accuracy, and quality expectations while maintaining careful attention to detail.

• Submit medical authorizations based on payer preferences and follow up until a determination is made.

• Participate in training, calibration sessions, and process updates related to payer rules, documentation standards, and internal procedures.

• Perform other documentation review and administrative support duties as assigned.

Qualifications

Required

• High school diploma or equivalent required; associate degree or relevant healthcare coursework preferred.

• Minimum of three years of experience reviewing and interpreting medical records, claims documentation, clinical documentation, insurance documentation, or related healthcare records.

• Working knowledge of medical terminology and the ability to understand documentation related to patient history, diagnoses, treatment plans, orders, and supporting clinical notes.

• Strong attention to detail and ability to identify documentation gaps, inconsistencies, and discrepancies.

• Excellent written and verbal communication skills, including the ability to summarize findings clearly and professionally.

• Ability to follow established criteria, checklists, standard procedures, and supervisory direction.

• Proficiency with Microsoft Office applications and the ability to learn claims, documentation, or case management systems.

• Ability to manage multiple cases or tasks while meeting established timelines and quality expectations.

Preferred

• Experience reviewing documentation for insurance medical necessity, prior authorization, utilization review support, durable medical equipment, home health, specialty pharmacy, or related claims processes.

• Experience using electronic medical record systems, payer portals, claims platforms, or document management tools.

• Familiarity with payer guidelines, coverage policies, audit documentation, or medical review workflows.