Medical Policy Reviewer I – Full Time Position

Job Details


LOCATION: US Remote or Onsite Location: WB PA.
STATUS: Full Time Position

REPORTS TO: Chief Operation Officer / Medical Director
Requisition Number: 20210423.04MRI

About Engage Health:

Engage is a fast-growing, innovative company focused on providing solutions for both public and private entities which improve payment accuracy in the healthcare industry. Engage Health provides technological and consultative solutions that meet the dynamic demands of the healthcare industry. We utilize sophisticated analytics to identify & correct irregularities in medical coding and billing which allows clients to enjoy improved financial performance.

Since our inception in 2016, Engage Health Solutions has excelled in the healthcare space. We are seeking to add to our healthcare team to enhance our company. The culture of the company is entrepreneurial, hardworking, and respectful of the work/life balance. We believe in, and reward, individuals who are motivated, accountable and work diligently to meet our collective goals.

Position Summary:

The Medical Policy Reviewer I (MPRl) perform pre & post bill clinical & policy review on Medical claims. As a MPRl, you will join a team of experienced clinical and coding professional performing which ensures claims are accurately subjected.

The MPRl will utilize their experience and Engage’s systems to decide as to the appropriateness and completeness of the medical claim. You will work in a fast paced and dynamic environment and be part of a medical review team. The successful candidate will be a team player able to collaborate with a variety of different entities to solve problems and generate solutions


  • Pre and post pay review of Medical claims to determine if the medical records support services for claim in both inpatient and outpatient settings
  • Applying appropriate Medical policy and rules
  • Maintains current knowledge federal, state and individual payer policy and coding guidelines.
  • Identifying and documenting any deficiencies, referencing the appropriate policies and rules, using a combination of policy application skills and independent judgment
  • Articulating any deficiencies or opportunities found in the claim to management and clients
  • Assist in education and training opportunities with clients using Engage’s templates, checklists, review guides, and the like.
  • Uses knowledge of healthcare coding conventions, audit risks, reimbursement policy application, and the clinical judgement to identify weakness or gaps in billing practices and medical record documentation.
  • Limited travel may be required


  • Active unrestricted, RN license (in good standing with 3+ years of clinical experience)
  • Strong preference for experience performing utilization review for an insurance company, Tricare, MAC or organizations performing similar functions
  • Experience with utilization management systems or clinical decision-making tools such as Medical Coverage Guidelines (MCG) or InterQual experience with ICD-10, CPT or HCPCS coding.
  • 2-5 years of related experience in medical record review with focus on policy application
  • Knowledge of the Medicare program and medical reimbursement policy particularly the coverage and payment rules.
  • Ability to maintain high quality work while meeting strict deadlines.
  • Excellent analytical, written and verbal communication skills.
  • Not currently sanctioned or excluded from the Medicare program by the OIG.
  • Ability to manage multiple tasks including desk audits and claims review.
  • Ability to work independently as well as in a team environment.
  • Coding certification is a plus.
  • Strong knowledge of medical documentation.
  • Courteous, professional, and respectful attitude.
  • Flexibility to handle any non-standard situations that may arise.
  • Proficient on PC and related software programs

Physical Requirement:

  • Sit/stand/ walk/8-10hr/day
  • Lift/carry/push/pull under and over 10lbs occasionally
  • Keying frequency, handling, reaching, fine manipulation


Engage offers a full compensation and benefits package that includes:

  • Competitive salary
  • Employee Bonus Program
  • Health insurance including vision and dental
  • Paid time off and holidays

If you are interested in this position, please e-mail us your resume.

Engage Health Solutions is an Equal Opportunity Employer (Minorities/Females/Disabled/Veterans).