RN Medical Reviewer - South Carolina

Job Summary

Performing medical reviews using clinical information and established guidelines, the full-time RN Medical Reviewer - South Carolina will evaluate medical claims, determine coverage necessity, and document decisions while working remotely from home.

Key responsibilities

• Conduct medical claim reviews for complex services, preauthorization requests, and potential fraud referrals
• Determine medical necessity and document rationales for payment or denial of services
• Participate in quality control activities and provide education to both medical and non-medical staff

Required qualifications

• Active RN licensure in the state of employment or a compact multistate RN license
• Associate degree in Nursing or graduation from an accredited School of Nursing
• Two years of clinical experience as a registered nurse
• Working knowledge of word processing software and Microsoft Office
• Ability to handle confidential information with discretion