Remote RN Medical Reviewer II - Claims & Utilization

Palmetto GBA, LLC

Tennessee

Remote

USD 65,000 - 90,000

Full time

4 days ago

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Benefits offered by this job

Subsidized health plans, dental and视觉?

401k retirement savings plan with公司匹配

Life Insurance

Paid Time Off (PTO)

On-site cafeterias and fitness centers

Education Assistance

Service Recognition

National discounts to movies, theaters

Job summary

Palmetto GBA is seeking an experienced registered nurse to perform medical reviews and determine medical necessity based on guidelines. This remote, full-time role requires an active RN license and at least two years of clinical experience.

Work from a private home office during 8:00 AM–5:00 PM ET, Monday through Friday, with occasional overtime. You’ll support quality control, educate staff, and handle confidential information while using Microsoft Office and standard clinical guidelines.

Qualifications

Active RN licensure in state hired or compact multistate license as defined by NLC.
Associate degree in Nursing or graduate of accredited School of Nursing.
Two years of clinical RN experience.
Working knowledge of word processing software; ability to work independently and make sound decisions.
Strong communication, judgment, and organizational skills; ability to handle confidential information.

Responsibilities

Perform medical claim reviews based on criteria/protocols and guidelines.
Determine medical necessity and document rationale for payment decisions; educate staff on reviews and coding procedures.
Support quality control and provide guidance to LPN team; assist with special projects as assigned by management.