[Hiring] RN Medical Reviewer II @Palmetto GBA

Role Description

Performs medical reviews using clinical/medical information provided by physicians/providers and established criteria/protocol sets or clinical guidelines. Documents decisions using indicated protocol sets or clinical guidelines. Provides support and review of medical claims and utilization practices.

This position is full-time (40 hours/week) Monday through Friday in a typical office environment. This role is remote position for South Carolina, Georgia, North Carolina or Alabama.

What You'll Do:

• Perform medical claim reviews for one or more of the following:
  • Claims for medically complex services
  • Services that require preauthorization/predetermination
  • Requests for appeal or reconsideration
  • Referrals for potential fraud and/or abuse
  • Correct coding for claims/operations
• Make reasonable charge payment determinations based on clinical/medical information and established criteria/protocol sets or clinical guidelines.
• Determine medical necessity and appropriateness and/or reasonableness and necessity for coverage and reimbursement.
• Monitor process’s timeliness in accordance with contractor standards.
• Document medical rationale to justify payment or denial of services and/or supplies.
• Educate internal/external staff regarding medical reviews, medical terminology, coverage determinations, coding procedures, etc. in accordance with contractor guidelines.
• Participate in quality control activities in support of the corporate and team-based objectives.
• Provide guidance, direction, and input as needed to LPN team members.
• Provide education to non-medical staff through discussions, team meetings, classroom participation, and feedback.
• Assist with special projects and specialty duties/responsibilities as assigned by management.

Qualifications

• Associate's in a job related field
• Graduate of Accredited School of Nursing.

Requirements

• Active RN licensure in state hired, OR, active compact multistate RN license as defined by the Nurse Licensure Compact (NLC).
• 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.

Benefits

• 401(k) retirement savings plan with company match
• Subsidized health plans, dental and vision coverage
• Life insurance
• Paid Time Off (PTO)
• Nine paid holidays
• On-site cafeterias and fitness centers in significant locations
• Wellness programs and a healthy lifestyle premium discount
• Tuition assistance
• Service Recognition