Medical Reviewer II

This is a fully remote position, open to applicants in Alabama, +2 more states.

📋 Description

• Conduct reviews of medical claims for complex services, including preauthorization/predetermination requests, appeals or reconsiderations, referrals for potential fraud and/or abuse, and accurate coding for claims and operations.

• Make payment decisions based on clinical medical information and established criteria, protocol sets, or clinical guidelines.

• Assess medical necessity, appropriateness, and reasonableness for coverage and reimbursement.

• Ensure process timeliness aligns with contractor standards.

• Document the medical rationale that supports the approval or denial of services and supplies.

• Provide education to both internal and external staff regarding medical reviews, terminology, coverage decisions, and coding practices.

• Engage in quality control activities that support corporate and team objectives.

• Offer guidance, direction, and feedback to LPN team members.

• Educate non-medical personnel through discussions, team meetings, classroom participation, and constructive feedback.

• Assist with special projects and specific duties as assigned by management.

⛳️ Requirements

• Valid RN licensure in the state of employment, or a valid compact multistate RN license as per the Nurse Licensure Compact (NLC).

• Associate degree in Nursing or completion of an accredited School of Nursing.

• Minimum of two years of clinical experience as an RN.

• Proficient in word processing software.

• Ability to work independently, prioritize tasks effectively, and make informed decisions.

• Strong judgment skills.

• Proven customer service and organizational abilities.

• Excellent oral and written communication skills.

• Strong analytical or critical thinking capabilities.

• Capacity to handle confidential or sensitive information with care.

• Proficient in Microsoft Office.

• Required experience in acute care.

• Preferably capable of using multiple Windows-based programs concurrently.

• Preferred three years of diverse RN nursing experience, encompassing Medical/Utilization Review, Quality Assurance, Emergency, Critical Care, or Medical/Surgical settings.

• Experience with Medicare or claims is a plus.

• Critical care experience is preferred.

• Prior medical review/utilization review experience is preferred.

🏝️ Benefits

• Subsidized health insurance plans.

• Dental and vision insurance coverage.

• 401k retirement savings plan with company match.

• Life insurance.

• Paid Time Off (PTO).

• On-site cafeterias and fitness centers at major locations.

• Education assistance.

• Service recognition programs.

• National discounts for movies, theaters, zoos, theme parks, and more.

• Reasonable accommodations for disabilities, pregnancy-related conditions, and sincerely held religious beliefs.

• Pay differential coverage for full-time employees in the National Guard or Reserves called to active duty.