RN Medical Reviewer II

This is a fully remote position, open to applicants in Alabama, +3 more states.

📋 Description

• Conduct 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 or operations.

• Make payment determinations 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 medical rationale that supports the payment or denial of services and supplies.

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

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

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

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

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

⛳️ Requirements

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

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

• A minimum of two years of clinical experience as a registered nurse (RN).

• Proficiency 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 manage confidential or sensitive information with discretion.

• Proficiency in Microsoft Office.

• Access to high-speed, non-satellite internet service.

• A private home office setup for remote work.

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

• Experience with Medicare or claims is advantageous.

• Preferred: Capability to use multiple Windows-based applications simultaneously.

🏝️ 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 in major locations.

• Education Assistance.

• Service Recognition.

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

• A diverse and inclusive workplace with opportunities for skill development and career advancement.

• Reasonable accommodations for individuals with disabilities, pregnancy-related conditions, or sincerely held religious beliefs.