Remote RN Medical Review Specialist II

Southcarolinablues; Northern (KY); Hybrid; USD 75,000 - 110,000; Full time

Benefits offered by this job

Health insurance

401k

Education assistance

PTO

Job summary

Palmetto GBA is seeking a remote RN Medical Reviewer II to assess medical claims and utilization according to established guidelines. Duties include determining coverage decisions, potential preauthorization, and education of internal staff.

Qualified candidates will hold an active RN license, have at least two years of clinical RN experience, and be proficient with Microsoft Office. Training begins 12/07/2026 with standard daily hours and possible overtime as needed.

Qualifications

• Active RN licensure in state hired or compact multistate license as defined by NLC.
• Associate degree in Nursing or graduate of an accredited School of Nursing.
• Two years of clinical RN experience.
• Ability to work independently and handle confidential information.
• Strong written and verbal communication skills.

Responsibilities

• Perform medical claim reviews using clinical information and guidelines to determine coverage.
• Determine medical necessity and payment determinations based on criteria and guidelines.
• Educate staff on medical reviews, terminology, coverage determinations, and coding procedures.
• Support quality control and provide guidance to LPN team members.
• Assist with special projects and duties as assigned by management.

Skills

RN experience

Decision making

Communication

Analytical thinking

Confidentiality

Education

Associate degree - Nursing

Graduate of accredited School of Nursing

Tools

Microsoft Office

Job description

Palmetto GBA is seeking a remote RN Medical Reviewer II to assess medical claims and utilization according to established guidelines. Duties include determining coverage decisions, potential preauthorization, and education of internal staff.

Qualified candidates will hold an active RN license, have at least two years of clinical RN experience, and be proficient with Microsoft Office. Training begins 12/07/2026 with standard daily hours and possible overtime as needed.