RN Medical Reviewer II

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

📋 Description

• Conduct medical claim evaluations for complex services, preauthorization/predetermination requests, appeals or reconsiderations, potential fraud and/or abuse referrals, and accurate coding.

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

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

• Oversee process timeliness in accordance with contractor standards.

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

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

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

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

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

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

⛳️ Requirements

• An associate's degree in a field related to the job.

• Graduate from an Accredited School of Nursing as a degree equivalency.

• A minimum of 2 years of clinical experience.

• Proficient in word processing software.

• Capacity 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.

• Analytical or critical thinking skills.

• Ability to manage confidential or sensitive information with care.

• Proficiency 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).

• High-speed (non-satellite) internet access and a dedicated home office.

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

• This position is not eligible for sponsorship at present or in the future.

🏝️ Benefits

• Subsidized health plans, including dental and vision coverage.

• 401k retirement savings plan with company matching contributions.

• Life Insurance coverage.

• Paid Time Off (PTO).

• Educational Assistance.

• Service Recognition.

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