Reviewer II, Medical
New
This role is remote position for South Carolina, Georgia, North Carolina or Alabama.Full-TimeMiddle
Salary not disclosed
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Job Details
- Experience
- 2 years clinical experience
- Required Skills
- Microsoft OfficeCritical thinking
Requirements
- Associate's degree in a job-related field or graduation from an accredited nursing school.
- Active RN licensure in the state of hire or active compact multistate RN license (NLC).
- 2 years of clinical experience.
- Working knowledge of word processing software.
- Proficiency in Microsoft Office.
- Ability to work independently and prioritize tasks effectively.
- Strong judgment, analytical, and critical thinking skills.
- Demonstrated oral and written communication skills.
- Strong customer service and organizational skills.
- Ability to handle confidential or sensitive information with discretion.
Responsibilities
- Perform medical claim reviews for complex services, preauthorizations, appeals, and potential fraud or abuse.
- Make reasonable charge payment determinations based on clinical guidelines and protocol sets.
- Determine medical necessity, appropriateness, and reimbursement coverage for medical services.
- Monitor process timeliness in accordance with contractor standards.
- Document medical rationale to justify payment or denial of services and supplies.
- Educate internal and external staff regarding medical reviews, terminology, and coding procedures.
- Participate in quality control activities and provide guidance to LPN team members.
- Assist with special projects and specialty duties as assigned.
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