Medical Reviewer II

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

📋 Description

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

• Make determinations on reasonable charge payments based on clinical/medical information and established criteria, protocol sets, or clinical guidelines.

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

• Track process timeliness in accordance with contractor standards.

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

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

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

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

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

• Assist with special projects and specialized tasks as assigned by management.

⛳️ Requirements

• Associate's degree in a relevant field.

• Graduate from an accredited nursing school.

• Two years of clinical experience.

• Proficient in word processing software.

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

• Strong judgment skills.

• Proven customer service and organizational abilities.

• Effective oral and written communication skills.

• Strong analytical or critical thinking skills.

• Ability to manage confidential or sensitive information with discretion.

• Proficiency in Microsoft Office.

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

• Ability to secure a security clearance.

• U.S. citizenship is required for security clearance.

• Availability to work an 8-hour shift during standard business hours, Monday to Friday.

• Occasional overtime may be necessary.

🏝️ Benefits

• Subsidized health plans, along with dental and vision coverage.

• 401k retirement savings plan with company matching.

• Life insurance coverage.

• Paid Time Off (PTO).

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

• Education assistance programs.

• Service recognition initiatives.

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