RN Medical Reviewer II

Job Description:

• Perform medical claim reviews for medically complex services, preauthorization/predetermination requests, appeals or reconsiderations, potential fraud and/or abuse referrals, and correct coding for claims or operations
• Make payment determinations using clinical medical information and established criteria, protocol sets, or clinical guidelines
• Determine medical necessity, appropriateness, reasonableness, 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 assigned by management

Requirements:

• Active RN licensure in the state hired, OR active compact multistate RN license as defined by the Nurse Licensure Compact (NLC)
• Associate degree in Nursing OR graduation from an accredited School of Nursing
• Two years of clinical experience as an RN
• 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 proficiency
• High-speed, non-satellite internet service
• Private home office for working from home
• Preferred: five years of varied RN nursing experience including Medical/Utilization Review, Quality Assurance, Emergency, Critical Care, or Medical/Surgical experience
• Medicare or claims experience is a plus
• Preferred: ability to use multiple Windows-based programs simultaneously

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
• Diverse and inclusive workplace with opportunities to develop skills and advance careers
• Reasonable accommodations for individuals with disabilities, pregnancy-related conditions, or sincerely held religious beliefs