Senior Clinical Reviewer

The range for this role is $31.97 per hour to $43.51 per hour

Actual base pay will be determined based on a successful candidate's work location, skills/abilities, experience, and education.

Interested applicants must be willing and able to work onsite minimum 4 times per week in either our Melbourne, FL or Orlando, FL office.

The Mission

At Christian Care Ministry we believe that Christians can, and should, share in one another’s burdens. Through the use of Medi-Share®, a healthcare sharing ministry for Christians, we cultivate that belief. To that end, our Mission Statement is as follows: Connecting people to a Christ-centered community wellness experience based on faith, prayer, and personal responsibility.

The Team

Everyone at Christian Care Ministry is in agreement with our Statement of Faith, which outlines our core beliefs. Although we aren’t perfect people, we are serving our perfect God and our Members to the best of our ability.

The Job

The Senior Clinical Reviewer works to summarize and correlate concise, accurate information on medical reviews to determine eligibility of medical bills per the program guidelines. In this role, 70% of the time is spent performing pre-service and post-service medical reviews and/or reviews for high dollar, complex medical cases and collaborating with other departments to optimize cost savings. This position leverages AI-enabled clinical review tools and electronically ingested data (278 transactions) to enhance the accuracy, efficiency, and consistency of medical reviews. The Senior Clinical Reviewer will be expected to make decisions regarding timing and omission of medical reviews in deference to other department processes based on the dollar amount of the bill and the Ministry’s cost strategy.

Essential Job Duties & Responsibilities

Organize and review medical records, lab results, radiology, and pathology reports for conditions ineligible for sharing (CIF’s)

Determine eligibility of members’ medical bills and/or upcoming procedures/treatments according to the program guidelines

Perform pre-service and post-service medical reviews utilizing AI-enabled clinical review tools to make evidence-based, consistent, and efficient determinations of sharing eligibility

Review and interpret pre-service eligibility data (via 278 EDI transactions) to support streamlined medical review workflows

Integrate structured electronic data with clinical documentation to support accurate and timely eligibility determinations

Collaborate with other departments to maximize cost savings for individual cases and optimal outcomes for the members

Appropriately apply the program guidelines to the individual cases reviewed

Work autonomously to prioritize and manage workload

Document effectively in appropriate systems, including outputs supported by AI tools and electronic data ingestion processes

Comply with all organizational HIPAA requirements and ensure proper handling of electronic transaction data

Support process improvements related to automation, using AI tools and electronic data ingestion workflows

Contribute to the exercise and expression of the Ministry’s Christian beliefs

All other duties as assigned

Essential Skills & Abilities

Understanding of medical bill processing and provider bill negotiation

Knowledge and practical application of AI-assisted medical review tools and clinical decision support technologies

Ability to understand Availity 278 transactions and electronic pre-service eligibility workflows

Ability to interpret structured electronic data and integrate it with clinical documentation during the medical review process

Ability to multitask in multiple operating systems

Ability to work for extended periods of time on the computer

Proficiency in interpreting medical records and writing detailed reports and conclusions

Strategic understanding of negotiations, third party processes, bill validation, and care management to determine when to utilize/defer to these processes for active review cases

Ability to be objective and impartial and conclude a case

Ability to communicate effectively with both internal and external customers

Interpersonal skills and ability to work as a member of a team

Ability to adapt to changing processes

Working knowledge and application of program guidelines

Understanding of systems and workflows as they relate to the type of review or assignment

Ability to utilize the internet including e-mail and search engines

Word processing skills of at least 25 wpm

Basic knowledge in Microsoft Office (Excel, Word, Outlook, Teams) and ability to use a database system

Knowledge of document imaging system

Core Competencies/Demonstrable Behaviors

Action Oriented – taking on new opportunities and tough challenges with a sense of urgency, high energy, and enthusiasm

Plans and aligns – planning and prioritizing work to meet commitments aligned with organizational goals

Member First – exhibits full commitment to serving members and/or clients by prioritizing their needs first in alignment with our program’s purpose. This commitment is demonstrated through understanding of the program(s), provided through quality and timely service while exercising empathy in every interaction. Every CCM employee shares responsibility to steward resources faithfully, removing barriers to understanding, and creating accessible, connected, and Christ-centered experiences.

Humble – demonstrates Christ-Centered humility by honoring others, accepting feedback, and prioritizing collective success over individual recognition

Hungry – exhibits initiative, perseverance, and commitment to serving God through excellence. Demonstrates passion for personal and organizational growth while diligently advancing the mission of Christian Care Ministry

Smart – shows relational and emotional intelligence, communicates effectively, collaborates harmoniously, and reads social cues with grace and discernment

Education and/or Experience

Current Unrestricted LPN/LVN license with 5+ years’ experience in a healthcare payer industry or RN license with sound knowledge of anatomy and physiology and disease processes

1-3 years’ experience in medical reviews required

2-3 years of clinical experience strongly preferred

Experience with Utilization Review or Case Management preferred

Supervisory Responsibilities

This job has no supervisory responsibilities

Incentives & Benefits

We work hard to serve our Medi-Share Members, but know we can only do that if we invest in our employees professionally, financially, physically, socially, and spiritually. We purposefully invest in our employees so that our employees can invest in others.

For full-time employees working 30 hours or more, some of our benefits include, but are not limited to:

100% paid Medical for employees/99% for family

Generous employer Health Savings Account (HSA) contributions

Employer-paid Life Insurance (3x salary) and Long-term Disability Insurance

6 weeks of paid parental leave (for both mom and dad)

Dental - two plans to choose from

Vision

Short-term Disability

Accident, Critical Illness, Hospital Indemnity

401(k) – up to 4% match on ROTH or Traditional contributions

Generous paid-time off and 11 paid holidays

Wellness plan including Financial, Occupational, Mental/Spiritual, and Physical health incentives up to $50/mo

Employee Assistance Program including no cost, in-person mental health visits and employee discounts

Monetary Anniversary Awards Program

Monetary Birthday Awards

Tuition Reimbursement Program

Minimum Age Requirement: Due to the nature of the responsibilities associated with this position—including independent decision-making, access to confidential information, and potential exposure to regulated environments—candidates must be at least 18 years of age at the time of hire. This requirement is in accordance with applicable federal and state labor laws and is intended to ensure compliance with workplace safety and legal standards.