South Carolina Licensed Medical Reviewer

Job Summary

To support medical claims processing, the full-time salaried South Carolina Licensed Medical Reviewer will perform medical reviews, document decisions based on clinical guidelines, and provide support for medical claims and utilization practices while working remotely.

Key responsibilities

• Conduct medical claim reviews for complex services, preauthorization requests, and appeals, making payment determinations based on established criteria
• Determine medical necessity and appropriateness for coverage, documenting rationale for payment or denial of services
• Participate in quality control activities and provide education to internal and external staff regarding medical reviews and coding procedures

Required qualifications

• Active RN licensure in South Carolina 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 and make sound decisions independently