South Carolina Licensed RN Medical Reviewer

Job Summary

A company is looking for an RN Medical Reviewer III to perform medical reviews and support medical claims and utilization practices.

Key Responsibilities

• Conducts medical claim reviews to determine medical necessity and appropriateness for coverage and reimbursement
• Educates internal and external staff on medical reviews, terminology, and coverage determinations
• Participates in quality control activities and provides guidance to team members

Required Qualifications

• Associates degree in a job-related field or equivalent from an accredited nursing school
• 2 years of clinical experience plus 1 year in utilization/medical review, or 3 years of clinical experience
• Active, unrestricted RN licensure in the state of hire or a compact multistate RN license
• Working knowledge of managed care and various healthcare delivery systems
• Proficiency in Microsoft Office software