RN Medical Reviewer II

Palmetto GBA

. Review home health and hospice documentation submitted by providers for required program elements, including face-to-face encounters, plans of care, and supporting clinical documentation .

Posted 11/2/2026full-timeRemote • South Carolina • United StatesJuniorMid-LevelWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in medical claim reviews, documentation analysis, and clinical guidelines to ensure compliance and accuracy in home health and hospice services. Proficient in educating staff and providing guidance while maintaining confidentiality and adhering to regulatory standards.

Highest-signal resume keywords

Active RN LicensureMedical Claim ReviewHome Health DocumentationCritical Thinking SkillsCustomer Service Skills

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Clinical Documentation ReviewMedical Necessity DeterminationCoding AccuracyCharge Payment DeterminationQuality Control Activities

Soft Skills

Organizational SkillsOral Communication SkillsWritten Communication SkillsAnalytical SkillsDecision-Making Skills

Tools & Technologies

Microsoft OfficeWord Processing Software

Certifications & Qualifications

Associate Degree – NursingActive Compact Multistate RN License

Industry Keywords

Home HealthHospiceFace-to-Face EncountersPlans of CarePreauthorization Requests

About the role

Key responsibilities & impact

Review home health and hospice documentation submitted by providers for required program elements, including face-to-face encounters, plans of care, and supporting clinical documentation
Perform medical claim reviews for medically complex services, preauthorization/predetermination requests, appeals or reconsiderations, potential fraud and/or abuse referrals, and coding accuracy
Make charge payment determinations using clinical information and established criteria, protocols, or clinical guidelines
Determine medical necessity, appropriateness, reasonableness, coverage, and reimbursement
Monitor review 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

Requirements

What you’ll need

Associate Degree – Nursing, OR graduate of an accredited School of Nursing
Two years clinical experience
Working knowledge of word processing software
Ability to work independently, prioritize effectively, and make sound decisions
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)
High-speed, non-satellite internet service and a private home office
Must be able to work full-time, 40 hours/week, Monday–Friday
Position is not eligible for sponsorship now or in the future
Preferred: critical care experience in a high-intensity setting such as ER or ICU
Preferred: home health and/or hospice experience
Preferred: familiarity with home health and hospice documentation requirements, such as face-to-face encounters and plans of care

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
Reasonable accommodations for disabilities, pregnancy-related conditions, and sincerely held religious beliefs, where applicable