RN Medical Reviewer - South Carolina

Job Summary

Performing medical reviews for claims and utilization practices, the full-time RN Medical Reviewer - South Carolina will evaluate clinical information, document decisions based on established guidelines, and provide support for medical claims in a remote work environment.

Key responsibilities

• Conduct medical claim reviews for complex services, preauthorization requests, and appeals, making payment determinations based on clinical data
• Assess medical necessity and appropriateness for coverage, documenting rationale for payment or denial of services
• Engage in quality control activities, providing guidance and education to team members and non-medical staff

Required qualifications

• Active RN licensure in the state of hire or an active 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 work independently, prioritize tasks, and make sound decisions