South Carolina Licensed Medical Reviewer

Job Summary

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

Key responsibilities

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

Required qualifications

• Active RN licensure in the state of 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 (RN)
• Proficiency in Microsoft Office and ability to work independently
• Demonstrated experience in medical/utilization review or related nursing fields preferred