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 or abuse, and ensuring 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, reasonableness, coverage, and reimbursement.

• Ensure process timeliness in accordance with contractor standards.

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

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

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

• Offer guidance, direction, and input to the LPN team members.

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

• Assist with special projects and specific tasks assigned by management.

⛳️ Requirements

• Valid RN licensure in the state of employment, or an active compact multistate RN license under the Nurse Licensure Compact (NLC).

• Associate degree in Nursing or graduation from an accredited School of Nursing.

• A minimum of two years of clinical experience as an RN.

• Proficient in word processing software.

• Capability to work independently, effectively prioritize tasks, and make sound judgments.

• Strong judgment abilities.

• Proven customer service and organizational skills.

• Excellent oral and written communication skills.

• Strong analytical or critical thinking skills.

• Ability to manage confidential or sensitive information with discretion.

• Proficiency in Microsoft Office.

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

• Required acute care experience; critical care and medical/utilization review experience preferred.

• Experience with Medicare or claims is advantageous.

• Ability to operate multiple Windows-based programs simultaneously.

• CMS residency requirement: must have lived in the US for at least three of the last five years.

• Must maintain a private and quiet home workspace with a reliable high-speed internet connection.

• Wired Ethernet connection is required; Wi-Fi, satellite internet, air cards, mobile hotspots, 5G home internet, and BPL are not permitted.

• Must be available to work an eight-hour shift during standard business hours, Monday through Friday, typically from 8:00 AM to 5:00 PM ET.

• No time off is allowed during the training period.

🏝️ Benefits

• Subsidized health insurance plans.

• Coverage for dental and vision care.

• 401k retirement savings plan with company matching contributions.

• Life insurance provided.

• Paid Time Off (PTO) available.

• On-site cafeterias and fitness centers located in major offices.

• Educational assistance offered.

• Recognition for service milestones.

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

• Training classes and programs designed to prepare employees for leadership roles.

• Tuition assistance for further education and career advancement.

• Opportunities for awards and financial incentives.