RN Medical Reviewer II

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

📋 Description

• Evaluate home health and hospice documentation submitted by providers to ensure compliance with program requirements, including face-to-face encounters, care plans, and supporting clinical documentation.

• Conduct medical claim assessments for complex services, including preauthorization/predetermination requests, appeals or reconsiderations, potential fraud or abuse referrals, and coding accuracy verification.

• Make payment determination decisions based on clinical information and established criteria, protocols, or clinical guidelines.

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

• Oversee review timelines in accordance with contractor standards.

• Record medical rationale to support either the approval or denial of services and supplies.

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

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

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

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

• Support special projects and additional duties as assigned by management.

⛳️ Requirements

• Associate Degree in Nursing, or a graduate from an accredited School of Nursing.

• Minimum of two years of clinical experience.

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

• Proficient in word processing software.

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

• Proven customer service and organizational abilities.

• Strong oral and written communication skills.

• Analytical or critical thinking capabilities.

• Ability to manage confidential or sensitive information with professionalism.

• Proficient in Microsoft Office.

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

• Dedicated private home office.

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

• Preferred: Experience in critical care within high-intensity environments such as the ER or ICU.

• Preferred: Experience in home health and/or hospice settings.

• Preferred: Understanding of documentation requirements for home health and hospice, including face-to-face encounters and care plans.

🏝️ Benefits

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

• 401k retirement savings plan with company matching contributions.

• Life Insurance.

• Paid Time Off (PTO).

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

• Education Assistance.

• Service Recognition.

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

• Opportunities to develop skills, advance careers, and contribute to the growth of the company.