South Carolina Licensed RN Medical Reviewer
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Job Summary
Working remotely in a full-time capacity, the South Carolina Licensed RN Medical Reviewer will perform medical reviews using clinical information, apply established guidelines, and support medical claims and utilization practices.
Key responsibilities
- Conducts medical claim reviews for complex services, preauthorization requests, and appeals
- Determines medical necessity and appropriateness for coverage and reimbursement based on clinical guidelines
- Educates internal and external staff on medical reviews, terminology, and coding procedures
Required qualifications
- Associate's degree in a job-related field or graduate of an accredited school of nursing
- Active RN licensure in South Carolina or a compact multistate RN license
- Minimum of 2 years of clinical experience
- Proficient in Microsoft Office and word processing software
- Ability to work independently and prioritize effectively
Complete Job Description
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