RN Medical Reviewer III (Reporting and Research) - Palmetto GBA
About the position Responsibilities • Perform medical claim reviews for complex services, preauthorization requests, appeals, and coding accuracy. • Make payment determinations based on clinical information and established guidelines. • Document medical rationale for payment or denial of services. • Educate internal and external staff on medical reviews, terminology, and coverage determinations. • Participate in quality control activities and provide guidance to LPN team members. • Assist with special projects and additional responsibilities as assigned. Requirements • Active, unrestricted RN licensure in the state of hire or compact multistate RN license. • Associate degree in Nursing or higher in a health-related field, or graduate of an accredited School of Nursing. • Two years of clinical experience plus two years in utilization/medical review or quality assurance. • Strong clinical experience in home health, rehabilitation, or medical-surgical settings. • Working knowledge of managed care and healthcare delivery systems. • Proficiency in Microsoft Office, particularly Excel for creating and manipulating spreadsheets. Nice-to-haves • Two years of reporting and research experience. • Intermediate skills in spreadsheet and word processing software, including the ability to create formulas and macros. Benefits • 401(k) retirement savings plan with company match. • Subsidized health plans and free vision coverage. • Life insurance. • Paid annual leave that increases with tenure. • Nine paid holidays. • On-site cafeterias and fitness centers in major locations. • Wellness programs and healthy lifestyle premium discount. • Tuition assistance for further education. • Service recognition programs. • Incentive and merit plans. • Continuing education funds for certifications. Apply tot his job