South Carolina RN Medical Reviewer

Job Summary

Working remotely after initial on-site training, the full-time RN Medical Reviewer III will perform medical reviews, document decisions based on clinical guidelines, and provide support for medical claims and utilization practices.

Key responsibilities:

• Conduct medical claim reviews to determine medical necessity and appropriateness for coverage and reimbursement
• Educate staff on medical reviews, terminology, coverage determinations, and coding procedures
• Participate in quality control activities and provide guidance to LPN team members

Required qualifications:

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