RN Medical Reviewer II

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

📋 Description

• Conducts medical reviews utilizing clinical/medical information supplied by physicians/providers along with established criteria/protocol sets or clinical guidelines.

• Records decisions based on the specified protocol sets or clinical guidelines.

• Offers support and reviews medical claims and utilization practices.

• Makes appropriate charge payment determinations by assessing clinical/medical information and established criteria/protocol sets or clinical guidelines.

• Evaluates medical necessity and appropriateness for coverage and reimbursement.

• Oversees the timeliness of processes according to contractor standards.

• Documents medical rationale to support payment or denial of services and/or supplies.

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

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

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

• Facilitates education for non-medical staff through discussions, team meetings, classroom participation, and feedback.

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

⛳️ Requirements

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

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

• Required Work Experience: 2 years of clinical experience.

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

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

• Strong judgment skills.

• Proven customer service and organizational skills.

• Excellent oral and written communication skills.

• Analytical or critical thinking abilities.

• Capacity 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 hire, 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 to movies, theaters, zoos, theme parks, and more.