South Carolina RN Medical Reviewer

Job Summary

To support medical review processes, the full-time RN Medical Reviewer III will perform medical claim reviews, document decisions based on clinical guidelines, and provide education and guidance to staff while working remotely after an initial training period in South Carolina.

Key responsibilities

• Conducts medical claim reviews for complex services and determines medical necessity based on established criteria
• Educates internal and external staff on medical reviews, terminology, and coding procedures
• Participates in quality control activities and provides guidance to LPN team members

Required qualifications

• Associate's degree in a job-related field or a graduate of an accredited school of nursing
• Minimum of 2 years clinical experience plus 1 year in utilization/medical review or quality assurance, or 3 years clinical experience
• Active, unrestricted RN licensure in the United States and in the state of hire
• Working knowledge of managed care and healthcare delivery systems
• Proficiency in Microsoft Office software