South Carolina Licensed Medical Reviewer

Job Summary

Performing medical reviews remotely, the full-time salaried South Carolina Licensed Medical Reviewer will assess medical claims for necessity and appropriateness, document decisions based on established guidelines, and provide education to staff regarding medical reviews and coding procedures.

Key responsibilities

• Conduct medical claim reviews for complex services, preauthorization requests, and appeals
• Determine medical necessity and document rationale for payment or denial of services
• Participate in quality control activities and provide guidance to team members

Required qualifications

• Active RN licensure in South Carolina or compact multistate RN license
• Associate degree in Nursing or graduate of an accredited School of Nursing
• Two years of clinical experience as an RN
• Working knowledge of Microsoft Office and word processing software
• Ability to work independently and prioritize effectively