Medical Reviewer II

Palmetto GBA · via CryptoJobsHub

🌎 Remote 📍 Remote, South Carolina ⏰ Full Time ⌛ Posted 3 days ago

Perform medical claim reviews for medically complex services, preauthorization/predetermination requests, appeals or reconsiderations, potential fraud and/or abuse referrals, and correct coding
Make reasonable charge payment determinations using clinical/medical information and established criteria, protocol sets, or clinical guidelines
Determine medical necessity, appropriateness, reasonableness, and necessity for coverage and reimbursement
Monitor process timeliness in accordance with contractor standards
Document medical rationale supporting payment or denial of services and supplies
Educate internal and external staff on medical reviews, medical terminology, coverage determinations, and coding procedures
Participate in quality control activities supporting corporate and team objectives
Provide guidance, direction, and input to LPN team members
Educate non-medical staff through discussions, team meetings, classroom participation, and feedback
Assist with special projects and specialty duties as assigned by management

Associate's in a job-related field
Graduate of Accredited School of Nursing
2 years clinical experience
Working knowledge of word processing software
Ability to work independently, prioritize effectively, and make sound decisions
Good judgment skills
Demonstrated customer service and organizational skills
Demonstrated oral and written communication skills
Analytical or critical thinking skills
Ability to handle confidential or sensitive information with discretion
Microsoft Office
Active RN licensure in state hired, OR, active compact multistate RN license as defined by the Nurse Licensure Compact (NLC)
Ability to obtain a security clearance
U.S. Citizen status required for security clearance
Ability to work an 8-hour shift during normal business hours, Monday-Friday
Occasional overtime may be required

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