Reviewer I, Medical

Experis; Columbia (SC); Remote; USD 40,000 - 54,000; Full time

Job summary

A dynamic healthcare organization is seeking a Utilization Management Nurse or Licensed Social Worker to join its remote team. This role involves performing medical reviews, managing claims, and ensuring authorization of services. Ideal candidates will appreciate the supportive culture and have the opportunity for professional development. Training occurs onsite for 1-2 weeks before transitioning to remote work. Candidates with strong analytical skills and effective communication talents are encouraged to apply.

Benefits

Collaborative team environment

Ongoing professional development opportunities

Supportive culture

Qualifications

• Minimum 2 years of clinical experience in a healthcare setting.
• Active, unrestricted LPN/LVN license or LBSW in state of hire required.
• Associate Degree in Nursing preferred.

Responsibilities

• Perform medical reviews using established criteria and guidelines.
• Review medical claims and determine reasonable charge payments.
• Communicate determinations clearly to members and providers.

Skills

Analytical skills

Attention to detail

Communication skills

Interpersonal skills

Time management

Education

Bachelor's degree in Social Work

Graduate from an Accredited School of LPN or LVN

Tools

Microsoft Office

Microsoft Excel

Access

Job description

Location : Remote (Must Train Onsite for 1-2 Weeks) - Must Reside Within 3 Hours of Client Location

Max Pay Rate : $23.00 / hr

Schedule : Monday - Friday, 8 : 30 AM - 5 : 00 PM

Interview Format : Microsoft Teams

Job Overview

We are seeking a Utilization Management Nurse or Licensed Social Worker to perform medical reviews and utilization management for professional, inpatient, and outpatient services. This role requires strong analytical skills, attention to detail, and the ability to effectively communicate with members and healthcare providers.

Key Responsibilities

• Perform medical reviews using established criteria and guidelines.
• Review medical claims and determine reasonable charge payments.
• Ensure authorization of medical services based on benefit guidelines.
• Review interdepartmental requests for medical information to support utilization processes.
• Conduct high-dollar forecasting and patient health summaries.
• Assess risk and determine eligibility and medical necessity of services.
• Handle first-level appeals, ensuring detailed documentation of determinations.

Education & Communication (10%)

• Provide education to internal / external staff on medical reviews, terminology, coverage determinations, and coding procedures.
• Communicate determinations clearly and accurately to members and providers.

Quality Control & Training (10%)

• Participate in corporate quality control initiatives.
• Complete required training and support team-based objectives.

Required Qualifications

Education :

• Bachelor's degree in Social Work OR Graduate of an Accredited School of Licensed Practical Nursing (LPN) or Licensed Vocational Nursing (LVN).

Experience :

• Minimum 2 years of clinical experience in a healthcare setting.

Licenses & Certifications :

• Active, unrestricted LPN / LVN license OR LBSW (Licensed Bachelor of Social Work) in the U.S. and state of hire.

Preferred Qualifications

Education :

• Associate Degree in Nursing OR Graduate of an Accredited School of Nursing.

Licenses & Certifications :

• Active, unrestricted RN license OR compact multistate RN license (NLC).

Software & Tools :

• Required : Microsoft Office, strong typing and computer skills.
• Preferred : Microsoft Excel, Access, or other database / spreadsheet software.

Key Soft Skills

Detail-oriented and highly organized.

Strong communication and interpersonal skills.

Effective time management and prioritization.

Ability to work independently and as part of a team.

• Remote role after 1-2 weeks of onsite training .
• Highly collaborative team of 22 nurses , working closely with other utilization management teams.
• Supportive, team-oriented culture with ongoing professional development opportunities.

Typical Day in This Role

• Log in at 8 : 30 AM , review workload, and prioritize tasks.
• Process electronic faxes and phone requests.
• Review requests against policies and member contracts.
• Determine if a case can be handled at the current level or needs escalation.
• Complete approvals or denials and notify providers accordingly.

Interview & Hiring Process

• Virtual interview via Microsoft Teams .
• Must train onsite before transitioning to remote work .

If you meet the qualifications and are interested in joining a collaborative and mission-driven team, apply today!

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