South Carolina Licensed Medical Reviewer

Job Summary

A company is looking for a Medical Reviewer II to perform medical reviews and support medical claims processing.

Key Responsibilities

• Conducts medical claim reviews for complex services and preauthorization requests
• Determines medical necessity and appropriateness for coverage and reimbursement
• Documents medical rationale for payment or denial of services and educates staff on medical reviews

Required Qualifications, Training, and Education

• Associate's degree in a job-related field or graduate of an accredited school of nursing
• 2 years of clinical experience required
• Active RN licensure in the state hired or active compact multistate RN license
• Working knowledge of Microsoft Office and ability to work independently
• Experience in customer service and organizational skills