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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 .
Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in medical claim reviews, payment determinations, and medical necessity assessments while providing guidance to nursing teams. Proficient in educating staff on medical terminology, coding procedures, and quality control activities.
Highest-signal resume keywords
Active RN LicensureClinical Experience as an RNMedical/Utilization Review ExperienceMicrosoft Office ProficiencyAnalytical or Critical Thinking Skills
ATS Keywords
Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
Medical Claim ReviewPayment DeterminationMedical Necessity AssessmentCoding ProceduresQuality AssuranceClinical GuidelinesDocumentation SkillsCustomer ServiceConfidential Information HandlingDecision-Making
Soft Skills
Organizational SkillsOral Communication SkillsWritten Communication SkillsJudgment SkillsAbility to Work Independently
Tools & Technologies
Word Processing SoftwareWindows-Based ProgramsHigh-Speed Internet Service
Certifications & Qualifications
Active Compact Multistate RN LicenseAssociate Degree in Nursing
Industry Keywords
Medicare ExperienceClaims ExperienceClinical ExperiencePreauthorization RequestsFraud ReferralsReconsiderationsCoverage DeterminationsTimeliness MonitoringLPN GuidanceSpecial Projects
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 payment determinations using clinical medical information and established criteria, protocol sets, or clinical guidelines
- Determine medical necessity, appropriateness, reasonableness, and coverage/reimbursement eligibility
- Monitor process timeliness according to contractor standards
- Document medical rationale supporting payment or denial of services and supplies
- Educate internal and external staff on medical reviews, 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 assigned by management
- Complete six-week paid training, including one onsite week and five remote weeks
Requirements
What you’ll need- Active RN licensure in state hired, OR active compact multistate RN license as defined by the Nurse Licensure Compact (NLC)
- Associate degree in Nursing OR graduate of an accredited School of Nursing
- Two years of clinical experience as an RN
- 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 proficiency
- Preferred: five years of varied RN nursing experience including Medical/Utilization Review, Quality Assurance, Emergency, Critical Care, or Medical/Surgical experience
- Medicare or claims experience is a plus
- Ability to use multiple Windows-based programs simultaneously
- High-speed non-satellite internet service
- Private home office
- No time off permitted during training
- Ability to work Monday-Friday, 8-hour shifts during 8:00AM-5:00PM ET business hours
- Willingness to occasionally work additional hours
- Candidates must be eligible for employment in the state hired
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
- Six-week paid training class
- Diverse and inclusive workplace with opportunities to develop skills and advance careers