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Palmetto GBAPosted 10/21/2026full-timeRemote • South Carolina • United StatesMid-LevelSenior💰 $53,462 - $102,258 per yearWebsite
Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates strong clinical expertise in nursing with a focus on utilization review and quality assurance, while adhering to confidentiality regulations and compliance standards. Proficient in analyzing medical necessity and documenting decisions accurately within mandated timeframes.
Highest-signal resume keywords
Active RN LicenseClinical ExperienceUtilization ReviewAnalytical SkillsKnowledge of Managed Care
About the role
Key responsibilities & impact- Research the substance of complex appeal or retrospective review requests, including pre-pay and post-payment review appeal requests
- Provide thorough clinical review or benefit analysis to determine whether requested services meet medical necessity guidelines
- Document decisions within mandated timeframes and in compliance with applicable regulations or standards
- Document the basis of appeals or retrospective reviews accurately and timely
- Research service appeals by members and providers using clinical documentation, contractual requirements, governing agencies, policies and procedures
- Adhere to confidentiality regulations regarding protected health information
- Perform appeal and retrospective reviews by determining the precedence of pertinent issues when applying policies, procedures, clinical information, benefit provisions, or policy provisions
- Perform special projects, including reviews of clinical information to identify quality-of-care issues
Requirements
What you’ll need- Associate degree - Nursing or Graduate of Accredited School of Nursing
- Two years clinical experience plus one year utilization/medical review, quality assurance, or home health, OR 3 years clinical
- Working knowledge of word processing software
- Ability to work independently, prioritize effectively, and make sound decisions
- Working knowledge of managed care and various forms of health care delivery systems
- Strong clinical experience to include home health, rehabilitation, and/or broad medical surgical experience
- Knowledge of specific criteria/protocol sets and the use of the same
- Good judgment skills
- Demonstrated customer service, organizational, oral and written communication skills
- Ability to persuade, negotiate, or influence others
- Analytical or critical thinking skills
- Ability to handle confidential or sensitive information with discretion
- An active, unrestricted RN license from the United States and in the state of hire, OR active compact multistate unrestricted RN license as defined by the Nurse Licensure Compact (NLC)
- CMS residency requirement: employees must have lived in the US for at least three out of the last five years
- Preferred: three years utilization/medical review, quality assurance, or home health, plus five years clinical
- Preferred: Bachelor's degree- Nursing
- Preferred knowledge of Administrative Law Judge (ALJ) process, statistical principles, NCQA, URAC, SCDOI, US DOL and HIPAA standards/regulations, claims systems, and presentation skills
Benefits
Comp & perks- 401(k) retirement savings plan with company match
- Subsidized health plans and free vision coverage
- Life insurance
- Paid annual leave – the longer you work here, the more you earn
- Nine paid holidays
- On-site cafeterias and fitness centers in major locations
- Wellness programs and healthy lifestyle premium discount
- Tuition assistance
- Service recognition
- Incentive Plan
- Merit Plan
- Continuing education funds for additional certifications and certification renewal
ATS Keywords
✓ Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
Clinical ReviewBenefit AnalysisDocumentationQuality AssuranceMedical Necessity GuidelinesCriteria/Protocol SetsHome Health ExperienceRehabilitation ExperienceMedical Surgical ExperienceStatistical Principles
Soft Skills
Good JudgmentCustomer ServiceOrganizational SkillsOral CommunicationWritten CommunicationPersuasionNegotiationCritical ThinkingDiscretion
Tools & Technologies
Word Processing Software
Certifications & Qualifications
Active RN LicenseNurse Licensure Compact (NLC)
Industry Keywords
Managed CareHealth Care Delivery SystemsConfidentiality RegulationsCMS Residency RequirementALJ ProcessNCQAURACSCDOIUS DOLHIPAA Standards