Remote RN Medical Reviewer II — Claims & Guidelines

Palmetto GBA, LLC; South Carolina; À distance; USD 70 000 - 90 000; Plein temps

Avantages offerts par ce poste

Health insurance

401k retirement plan

Paid Time Off

Educational assistance

Résumé du poste

Palmetto GBA is seeking an RN Medical Reviewer II to join our Medical Review team. This remote, full-time role uses your clinical expertise to perform medical reviews, apply established guidelines, and assist with timely coverage determinations.

You will educate staff and contribute to quality goals, with regular hours 8:00 AM–5:00 PM ET, Monday–Friday. Qualified candidates have an RN license, at least two years of clinical experience, and proficiency with Microsoft Office.

Qualifications

• RN licensure in state of hire or a compact multistate license.
• At least 2 years of clinical experience.
• Experience with medical reviews and utilization review processes.

Responsabilités

• Perform medical claim reviews using clinical guidelines and criteria.
• Determine medical necessity and payment determinations.
• Educate internal/external staff on medical reviews and coding terminology.
• Support quality control and participate in special projects.

Connaissances

Word processing

Independent work

Judgment

Customer service

Communication (oral & written)

Analytical thinking

Formation

Associate's degree in a job-related field

Graduate of Accredited School of Nursing

Outils

Microsoft Office

Description du poste

Palmetto GBA is seeking an RN Medical Reviewer II to join our Medical Review team. This remote, full-time role uses your clinical expertise to perform medical reviews, apply established guidelines, and assist with timely coverage determinations.

You will educate staff and contribute to quality goals, with regular hours 8:00 AM–5:00 PM ET, Monday–Friday. Qualified candidates have an RN license, at least two years of clinical experience, and proficiency with Microsoft Office.