Medical Reviewer II

Palmetto GBA

. Perform medical claim reviews for medically complex services, preauthorization/predetermination requests, appeals or reconsiderations, potential fraud and/or abuse referrals, and correct coding .

Posted 10/12/2026full-timeRemote • South Carolina • United StatesJuniorMid-LevelWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in medical claim reviews, clinical guidelines, and coding procedures while providing guidance to nursing team members. Proficient in documentation, communication, and analytical skills to support coverage determinations and quality control activities.

Highest-signal resume keywords

Active RN LicensureMedical Claim ReviewClinical GuidelinesAnalytical SkillsCustomer Service

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Medical Necessity DeterminationCoding ProceduresClinical ExperienceDocumentation SkillsQuality Control Activities

Soft Skills

Good JudgmentOrganizational SkillsOral CommunicationWritten CommunicationAbility to Work Independently

Tools & Technologies

Microsoft OfficeWord Processing Software

Certifications & Qualifications

Active RN LicensureNurse Licensure Compact (NLC) Compliance

Industry Keywords

Medical ReviewPreauthorization RequestsReconsiderationsFraud and Abuse ReferralsConfidential Information Handling

About the role

Key responsibilities & impact

Perform medical claim reviews for medically complex services, preauthorization/predetermination requests, appeals or reconsiderations, potential fraud and/or abuse referrals, and correct coding
Make reasonable charge payment determinations using clinical/medical information and established criteria, protocol sets, or clinical guidelines
Determine medical necessity, appropriateness, reasonableness, and necessity for coverage and reimbursement
Monitor process timeliness in accordance with contractor standards
Document medical rationale supporting payment or denial of services and supplies
Educate internal and external staff on medical reviews, medical terminology, coverage determinations, and coding procedures
Participate in quality control activities supporting corporate and team objectives
Provide guidance, direction, and input to LPN team members
Educate non-medical staff through discussions, team meetings, classroom participation, and feedback
Assist with special projects and specialty duties as assigned by management

Requirements

What you’ll need

Associate's in a job-related field
Graduate of Accredited School of Nursing
2 years clinical experience
Working knowledge of word processing software
Ability to work independently, prioritize effectively, and make sound decisions
Good judgment 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
Microsoft Office
Active RN licensure in state hired, OR, active compact multistate RN license as defined by the Nurse Licensure Compact (NLC)
Ability to obtain a security clearance
U.S. Citizen status required for security clearance
Ability to work an 8-hour shift during normal business hours, Monday-Friday
Occasional overtime may be required

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