Remote RN Medical Reviewer II - Claims & Utilization

Palmetto GBA, LLC; United States; A distancia; USD 75.000 - 95.000; Jornada completa

Ventajas ofrecidas por este puesto de trabajo

Health insurance

401k retirement plan

Paid Time Off

Descripción de la vacante

Palmetto GBA, LLC is seeking a registered nurse to perform medical reviews using clinical information and established guidelines. This full-time, remote role involves reviewing claims, determining medical necessity, and documenting decisions to support payment determinations.

You will collaborate with internal teams, provide guidance to staff, and participate in quality control. A nursing license and 2 years of RN experience are required; candidates in SC or AL preferred.

Formación

• Active RN license in state hired or compact multistate license as defined by NLC.
• Two years of clinical RN experience.
• Working knowledge of word processing software.
• Ability to work independently, prioritize effectively, and make sound decisions.
• Strong customer service and organizational skills.
• Demonstrated oral and written communication skills.

Responsabilidades

• Perform medical claim reviews for medical necessity, applicability, and/or reasonableness using established criteria and clinical guidelines.
• Document medical rationale to justify payment or denial of services and educate staff.
• Participate in quality control activities and provide guidance to LPN team members and other staff.

Conocimientos

Word processing

Independent work

Prioritization

Decision making

Communication

Analytical thinking

Educación

Associate degree in Nursing

Herramientas

Microsoft Office

Descripción del empleo

Palmetto GBA, LLC is seeking a registered nurse to perform medical reviews using clinical information and established guidelines. This full-time, remote role involves reviewing claims, determining medical necessity, and documenting decisions to support payment determinations.

You will collaborate with internal teams, provide guidance to staff, and participate in quality control. A nursing license and 2 years of RN experience are required; candidates in SC or AL preferred.