RN Medical Reviewer II

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

📋 Description

• Review documentation from home health and hospice providers to ensure compliance with required program elements, including face-to-face encounters, care plans, and supporting clinical records.

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

• Make determinations regarding charge payments based on clinical data and established criteria, protocols, or clinical guidelines.

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

• Ensure timely reviews in accordance with contractor standards.

• Document the medical rationale that supports either the payment or denial of services and 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 insights to LPN team members.

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

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

⛳️ Requirements

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

• Minimum of two years of clinical experience.

• Proficiency in word processing software.

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

• Proven customer service and organizational abilities.

• Strong oral and written communication skills.

• Analytical and critical thinking capabilities.

• Capacity to manage confidential or sensitive information with care.

• Proficient in Microsoft Office.

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

• Access to high-speed, non-satellite internet service and a private home office.

• Availability to work full-time, 40 hours per week, Monday through Friday.

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

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

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

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

🏝️ Benefits

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

• 401k retirement savings plan featuring company matching.

• Life Insurance coverage.

• Paid Time Off (PTO).

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

• Education Assistance programs.

• Service Recognition initiatives.

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

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