Medical Reviewer II

This is a fully remote position, open to applicants in South Carolina.

📋 Description

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

• Makes informed charge payment determinations based on clinical/medical information and established criteria, protocol sets, or clinical guidelines.

• Assesses medical necessity, appropriateness, and reasonableness for coverage and reimbursement decisions.

• Monitors the timeliness of processes in line with contractor standards.

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

• Provides education to both internal and external staff on medical reviews, medical terminology, coverage determinations, and coding practices.

• Engages in quality control initiatives that align with corporate and team objectives.

• Offers guidance, direction, and input to LPN team members.

• Instructs non-medical personnel through discussions, team meetings, classroom involvement, and feedback.

• Supports special projects and additional responsibilities assigned by management.

⛳️ Requirements

• Associate's degree in a relevant field.

• Graduate from an accredited nursing school.

• A minimum of 2 years of clinical experience.

• Proficient in word processing software.

• Capable of working independently, effectively prioritizing tasks, and making sound decisions.

• Strong judgment skills.

• Proven customer service and organizational abilities.

• Excellent oral and written communication skills.

• Strong analytical or critical thinking skills.

• Ability to manage confidential or sensitive information with discretion.

• Proficient in Microsoft Office.

• Active RN licensure in the state of employment, or an active compact multistate RN license as defined by the Nurse Licensure Compact (NLC).

• U.S. Citizenship is required to obtain the necessary security clearance.

• Availability to work an 8-hour shift during standard business hours, Monday to Friday, with occasional overtime as needed.

🏝️ Benefits

• Subsidized health plans, dental and vision 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.

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