Medical Reviewer

This is a fully remote position, open to applicants in United States.

📋 Description

• Manage claim categories such as Radiology, Ambulance, Physical Therapy, and Surgical.

• Utilize clinical information, Medicare guidelines, and established criteria to assess medical necessity, coverage, and payment.

• Record medical review decisions along with the rationale behind the approval or denial of services and supplies.

• Evaluate medically intricate claims, preauthorization or predetermination requests, appeals and reconsiderations, potential fraud and abuse referrals, and accurate coding reviews.

• Provide education to both internal and external staff regarding medical review processes, terminology, coverage determinations, and coding practices.

• Offer guidance and direction to LPN team members as necessary.

• Engage in quality control initiatives.

• Support special projects and specialty assignments as directed by management.

⛳️ Requirements

• An active, unrestricted RN license in the U.S. and in the state of hire, or a valid, unrestricted multistate RN license under the Nurse Licensure Compact.

• An Associate’s degree in nursing or a graduate of an accredited nursing program.

• A minimum of 2 years of clinical experience along with 2 years in utilization or medical review, quality assurance, or home health.

• Experience in home health, rehabilitation, and/or extensive medical-surgical practices.

• A solid understanding of criteria and protocol sets, managed care, and healthcare delivery systems.

• Proficiency in Microsoft Office applications.

• Excellent written and verbal communication skills.

• Strong judgment and critical thinking abilities.

• Capability to work independently, prioritize tasks, and manage confidential information.

• Must be able to pass the CMS background investigation and complete fingerprinting and EUA/system access clearance promptly.

• Residency within a three-hour driving radius of Augusta, GA is required.

🏝️ Benefits

• 401(k) plan with company matching contributions.

• Paid Time Off (PTO) that increases with tenure.

• Health, Vision, and Dental insurance.

• Company-provided Life Insurance and optional Voluntary Life Insurance.

• Short-Term and Long-Term Disability coverage.

• A comprehensive benefits package.