Remote RN Medical Reviewer II – Claims & Coverage

Palmetto GBA, LLC; Northern (KY); Hybrid; USD 65,000 - 90,000; Full time

Benefits offered by this job

401(k) retirement savings plan with公司

Health plans

Paid Time Off

Nine paid holidays

Job summary

Palmetto GBA, LLC, a BlueCross BlueShield subsidiary, seeks a Remote RN Medical Reviewer II to assess medical claims using guidelines. The role is full-time, Monday–Friday, with remote work available for SC, GA, NC or AL.

You will review complex services, determine medical necessity, educate staff, and participate in quality control. Requires RN licensure and 2 years clinical experience; benefits include 401(k), health plans, PTO.

Qualifications

• Active RN licensure in state hired or compact multistate license.
• 2 years clinical experience required.
• Strong communication and organizational skills.
• Ability to work independently and handle confidential information.

Responsibilities

• Perform medical claim reviews using guidelines and criteria.
• Determine medical necessity and coverage/reimbursement.
• Educate staff on medical reviews, terminology, and procedures.
• Participate in quality control and process improvements.

Skills

RN licensure

Clinical experience

Independent worker

Communication skills

Education

Associate's in a related field

Tools

Microsoft Office

Job description

Palmetto GBA, LLC, a BlueCross BlueShield subsidiary, seeks a Remote RN Medical Reviewer II to assess medical claims using guidelines. The role is full-time, Monday–Friday, with remote work available for SC, GA, NC or AL.

You will review complex services, determine medical necessity, educate staff, and participate in quality control. Requires RN licensure and 2 years clinical experience; benefits include 401(k), health plans, PTO.