Medical Claims Reviewer I: Remote After Training

Palmetto GBA, LLC; Myrtle Beach (SC); Hybrid; USD 42,000 - 64,000; Full time

Benefits offered by this job

Subsidized health plans

401k retirement plan

Life Insurance

Paid Time Off (PTO)

On-site cafeterias

Job summary

Palmetto GBA, LLC is seeking a qualified professional to support medical claims review and utilization management. The role involves evaluating inpatient, outpatient, and professional services, ensuring coverage aligns with medical necessity guidelines and documenting determinations.

Training will be provided onsite, with remote work possible after six months of onsite onboarding. The ideal candidate holds a state LPN/LVN license or LBSW and has at least two years of clinical experience, strong

Qualifications

• Bachelor's degree in Social Work or graduate of an accredited LPN/LVN program.
• Licensed or eligible for licensure in the United States as applicable (LPN/LVN or LBSW).
• Minimum 2 years clinical experience.

Responsibilities

• Perform medical claim reviews and determinations of coverage/necessity.
• Process authorizations and ensure medical services align with guidelines.
• Educate members/families and respond to member/provider inquiries with documentation.

Skills

Word processing

Customer service

Attention to detail

Analytical thinking

Discretion with confidential info

Education

Bachelor's degree - Social Work

LPN/LVN or LBSW credential

Tools

Microsoft Office

Job description

Palmetto GBA, LLC is seeking a qualified professional to support medical claims review and utilization management. The role involves evaluating inpatient, outpatient, and professional services, ensuring coverage aligns with medical necessity guidelines and documenting determinations.

Training will be provided onsite, with remote work possible after six months of onsite onboarding. The ideal candidate holds a state LPN/LVN license or LBSW and has at least two years of clinical experience, strong