RN Medical Reviewer II

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

📋 Description

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

• Make payment decisions based on clinical/medical information along with established criteria, protocols, or clinical guidelines.

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

• Ensure process timeliness adheres to contractor standards.

• Document the medical rationale that supports either 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 input to LPN team members.

• Educate non-medical personnel through discussions, team meetings, classroom involvement, and constructive feedback.

• Assist with special projects and additional responsibilities assigned by management.

⛳️ Requirements

• Associate's degree in a related field.

• Graduate from an accredited nursing school as a degree equivalent.

• A minimum of 2 years of clinical experience.

• Proficiency in word processing software.

• Capability 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.

• Strong analytical or critical thinking abilities.

• Ability to manage confidential or sensitive information with care.

• Proficient in Microsoft Office.

• Active RN licensure in the state of hire, OR an active compact multistate RN license as per the Nurse Licensure Compact (NLC).

• Access to high-speed (non-satellite) internet service and a dedicated home office.

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

🏝️ Benefits

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

• 401k retirement savings plan featuring a company match.

• Life insurance coverage.

• Paid Time Off (PTO).

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

• Education assistance programs.

• Service recognition initiatives.

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