RN Medical Reviewer III

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

📋 Description

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

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

• Offers support and evaluates medical claims and utilization practices.

• Executes medical claim reviews for various scenarios, including claims for medically complex services, preauthorization/predetermination requests, appeals or reconsiderations, referrals for potential fraud and/or abuse, and ensures correct coding for claims and operations.

• Makes reasonable payment determinations for charges based on clinical and medical information as well as established criteria or clinical guidelines.

• Assesses medical necessity and appropriateness for coverage and reimbursement.

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

• Educates both internal and external staff on medical reviews, medical terminology, coverage determinations, and coding procedures in accordance with contractor guidelines.

• Engages in quality control activities that align with corporate and team objectives.

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

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

• Assists with special projects and other responsibilities as assigned by management.

⛳️ Requirements

• Associate Degree in Nursing, OR a four-year degree in a health-related field, OR a graduate of an accredited School of Nursing.

• Minimum of two years of clinical experience along with two years of utilization/medical review, quality assurance, or home health experience.

• Familiarity with managed care and various health care delivery systems.

• Strong clinical experience, particularly in home health, rehabilitation, and/or broad medical-surgical settings.

• Knowledge of specific criteria and protocols and their application.

• Proficient in word processing software.

• Capable of working independently, prioritizing tasks effectively, and making sound decisions.

• Good judgment skills.

• Proven customer service and organizational abilities.

• Effective oral and written communication skills.

• Ability to persuade, negotiate, or influence others.

• Strong analytical or critical thinking skills.

• Capability to manage confidential or sensitive information with discretion.

• Active, unrestricted RN licensure from the United States and the state of hire, OR an active compact multistate unrestricted RN license as per the Nurse Licensure Compact (NLC), OR current active unrestricted licensure/certification in the United States and the state of hire in the specialty area required by the hiring division/area.

🏝️ Benefits

• Opportunities for professional development.

• Awards and financial incentives.