South Carolina RN Medical Reviewer

Job Summary

A company is looking for a Medical Reviewer II who will perform medical reviews and support medical claims and utilization practices.

Key Responsibilities

• Conducts medical claim reviews for complex services and preauthorization requests
• Determines medical necessity and appropriateness for coverage and reimbursement
• Documents medical rationale for payment or denial of services and provides education to staff

Required Qualifications

• Associate's degree in a job-related field or graduate of an accredited school of nursing
• 2 years of clinical experience
• Active RN licensure in the state hired or active compact multistate RN license
• Working knowledge of Microsoft Office
• Ability to work independently and prioritize effectively