RN Medical Reviewer II

CGS Administrators, LLC

. Perform medical reviews using clinical and medical information from physicians/providers and established criteria, protocols, or clinical guidelines .

Posted 10/16/2026full-timeUnited StatesJuniorMid-LevelWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in performing medical reviews and documenting decisions in accordance with clinical guidelines and regulations. Proficient in analyzing clinical information and managing appeals while maintaining confidentiality and exercising sound judgment.

Highest-signal resume keywords

Active RN LicensureClinical ExperienceMedical Review ExpertiseAnalytical SkillsMicrosoft Office Proficiency

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Medical ReviewClinical DocumentationUtilization ReviewAppeals ManagementQuality-of-Care AnalysisClinical Guidelines ApplicationConfidential Information HandlingDecision-MakingCritical Thinking

Soft Skills

Customer Service SkillsOrganizational SkillsOral Communication SkillsWritten Communication SkillsJudgment Skills

Tools & Technologies

Word Processing SoftwareMicrosoft Office Suite

Certifications & Qualifications

Associate's Degree in NursingBachelor's Degree in Nursing (Preferred)Active Compact Multistate RN License (Preferred)

Industry Keywords

Home HealthHospiceCase ManagementUtilization Management

About the role

Key responsibilities & impact

Perform medical reviews using clinical and medical information from physicians/providers and established criteria, protocols, or clinical guidelines
Document decisions using applicable protocol sets or clinical guidelines
Provide support and review of medical claims and utilization practices
Document the basis of appeals or retrospective reviews accurately, timely, and in accordance with regulations or standards
Research member and provider service appeals using clinical documentation, contractual requirements, governing agencies, policies, and procedures
Perform appeal and retrospective reviews by applying policies, procedures, clinical information, and benefit or policy provisions
Conduct special projects reviewing clinical information to identify quality-of-care issues
Work remotely full-time, with a hybrid schedule of 3 onsite days and 2 remote days for candidates within 40 miles of Nashville, TN or Columbia, SC

Requirements

What you’ll need

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 under the Nurse Licensure Compact (NLC)
Working knowledge of word processing software
Microsoft Office proficiency
Ability to work independently, prioritize effectively, and make sound decisions
Good judgement skills
Demonstrated customer service and organizational skills
Demonstrated oral and written communication skills
Analytical or critical thinking skills
Ability to handle confidential or sensitive information with discretion
Must work 40 hours per week on an 8-hour Monday–Friday shift within 8:00am–4:30pm
Position is not eligible for sponsorship now or in the future
Preferred: Bachelor's degree in Nursing
Preferred: exposure to home health, hospice, case management, and/or utilization
Preferred: computer literacy and Microsoft Office Suite

Benefits

Comp & perks

Subsidized health plans, dental and vision coverage
401k retirement savings plan with company match
Life Insurance
Paid Time Off (PTO)
On-site cafeterias and fitness centers in major locations
Education Assistance
Service Recognition
National discounts to movies, theaters, zoos, theme parks and more
Opportunity to develop skills, advance careers and contribute to company growth
Reasonable accommodations for individuals with disabilities, pregnant individuals, pregnancy-related conditions, or sincerely held religious beliefs