Medical Reviewer II
Remote · South Carolina, United States or Alabama, United States
Job Summary
Medical Reviewer II responsible for performing medical claim reviews for complex services and utilization reviews, determining medical necessity and appropriate coverage using established criteria and clinical guidelines, documenting rationale, and educating staff. The role includes handling preauthorization/predetermination, referrals for potential fraud/abuse, correct coding for claims, monitoring timeliness, participating in quality control, and providing guidance to LPNs and non-medical staff. Training includes six weeks with onsite and remote components, with initial onsite training in Columbia, SC, or Birmingham, AL.
Required Qualifications
- Active RN licensure in state hired or active compact multistate RN license as defined by the Nurse Licensure Compact (NLC)
- Education: Associate degree - Nursing OR Graduate of 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
- Software and Tools: Microsoft Office
Additional Requirements
- CMS residency requirement: employees must have lived in the US for at least three out of the last five years (business requirement, not HR requirement)
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