RN Medical Reviewer II

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

📋 Description

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

• Make determinations regarding charge payments based on clinical and medical information along with established criteria, protocol sets, or clinical guidelines.

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

• Oversee process timeliness in accordance with contractor standards.

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

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

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

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

• Instruct non-medical staff through discussions, team meetings, classroom involvement, and feedback.

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

⛳️ Requirements

• Associate's degree in a relevant field.

• Graduate of an Accredited School of Nursing.

• A minimum of 2 years of clinical experience.

• Proficient in word processing software.

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

• Strong judgment skills.

• Proven customer service and organizational abilities.

• Effective oral and written communication skills.

• Possess 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).

• Capability to obtain a security clearance.

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

🏝️ Benefits

• Subsidized health plans, including dental and vision coverage.

• 401k retirement savings plan with company matching contributions.

• Life insurance coverage.

• Paid Time Off (PTO).

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

• Education assistance programs.

• Recognition for service milestones.

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