Reviewer I, Medical

Experis; Columbia (SC); Remote; USD 80,000 - 100,000; Full time

Job summary

An established industry player is seeking a Utilization Management Nurse or Licensed Social Worker to join their collaborative team. This role, primarily remote after initial training, involves performing medical reviews and managing utilization for both inpatient and outpatient services. Ideal candidates will possess strong analytical skills and a detail-oriented mindset, ensuring accurate communication with healthcare providers and members. Join a supportive environment that emphasizes professional growth and teamwork, where your contributions will directly impact patient care and service quality.

Qualifications

• 2+ years of clinical experience in a healthcare setting required.
• Active LPN/LVN license or LBSW in the U.S. is mandatory.

Responsibilities

• Perform medical reviews and manage utilization for services.
• Educate staff on medical reviews and communicate determinations.

Skills

Analytical Skills

Attention to Detail

Communication Skills

Time Management

Education

Bachelor's Degree in Social Work

Graduate of Accredited School of Nursing

Tools

Microsoft Office

Microsoft Excel

Database/Spreadsheet Software

Job description

Utilization Management Nurse / Social Worker (Contract Position)

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

Medical Review & Utilization Management (80%)

• 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.

                  
                  
                  Work Environment & Team Culture
                  
                  
                  
                  
                  • 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!