RN Medical Reviewer II

📋 Description

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

• Makes informed payment determinations based on clinical or medical information along with established criteria, protocol sets, or clinical guidelines.

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

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

• Records medical justification for payment or denial of services and/or supplies.

• Instructs both internal and external staff on medical reviews, medical terminology, coverage determinations, coding procedures, and more, following contractor guidelines.

• Engages in quality control activities to support corporate and team-based objectives.

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

• Provides educational support to non-medical staff through discussions, team meetings, classroom participation, and feedback.

• Assists with special projects and additional responsibilities as assigned by management.

⛳️ Requirements

• Required Education: Associate's degree in a job-related field.

• Degree Equivalency: Graduate from an Accredited School of Nursing.

• Required Work Experience: Minimum of 2 years of clinical experience.

• Required Skills and Abilities: Proficient understanding of word processing software.

• Ability to work independently, prioritize tasks effectively, and make sound decisions.

• Strong judgment skills.

• Proven customer service and organizational abilities.

• Excellent oral and written communication skills.

• Capable of analytical or critical thinking.

• Ability to manage confidential or sensitive information with discretion.

• Required Software and Tools: Microsoft Office.

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

🏝️ 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 for movies, theaters, zoos, theme parks, and more.