RN Medical Reviewer II

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

📋 Description

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

• Make payment decisions based on clinical medical data and established guidelines, protocols, or clinical standards.

• Assess medical necessity, appropriateness, reasonableness, coverage, and reimbursement criteria.

• Oversee process timeliness in accordance with contractor standards.

• Record medical justifications for either the approval or denial of services and supplies.

• Train both internal and external personnel on medical reviews, medical terminology, coverage decisions, and coding processes.

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

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

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

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

• Work Monday through Friday on an 8-hour shift scheduled between 8:00 AM and 5:00 PM ET business hours.

• Begin training on December 7, 2026.

⛳️ Requirements

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

• An associate degree in Nursing or a graduate from an accredited School of Nursing.

• Minimum of two years clinical experience as a Registered Nurse (RN).

• Proficient in word processing software.

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

• Strong judgment abilities.

• Proven customer service and organizational skills.

• Excellent oral and written communication capabilities.

• Strong analytical or critical thinking skills.

• Ability to manage confidential or sensitive information discreetly.

• Proficient in Microsoft Office applications.

• 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: proficiency in using multiple Windows-based applications concurrently.

• No time off is allowed during the training period.

🏝️ Benefits

• Subsidized health plans along with dental and vision coverage.

• 401k retirement savings plan with company match.

• Life Insurance coverage.

• Paid Time Off (PTO).

• Access to on-site cafeterias and fitness centers in major locations.

• Education Assistance programs.

• Service Recognition initiatives.

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

• Opportunities for skill development, career advancement, and contributions to company growth.

• Reasonable accommodations for disabilities, pregnancy-related conditions, and sincerely held religious beliefs.