RN 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 for claims/operations .

Posted 11/7/2026full-timeRemote • South Carolina • United StatesJuniorMid-LevelWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in medical claim reviews, charge payment determinations, and medical necessity assessments while effectively educating staff on medical terminology and coding procedures. Possesses strong analytical skills and the ability to handle confidential information with discretion.

Highest-signal resume keywords

Active RN LicensureMedical Claim ReviewCharge Payment DeterminationAnalytical SkillsCustomer Service Skills

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Medical Necessity AssessmentCoding ProceduresClinical GuidelinesQuality Control ActivitiesDocumentation Skills

Soft Skills

Good Judgment SkillsOrganizational SkillsOral Communication SkillsWritten Communication SkillsCritical Thinking Skills

Tools & Technologies

Microsoft OfficeWord Processing Software

Certifications & Qualifications

Associate's DegreeGraduate of Accredited School of NursingActive Compact Multistate RN License

Industry Keywords

Medical Claim ReviewsPreauthorization RequestsFraud ReferralsReimbursementConfidential Information

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 for claims/operations
Make 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 according to contractor standards
Document medical rationale supporting payment or denial of services and/or 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-based 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's degree in a job-related field
Graduate of Accredited School of Nursing as degree equivalency
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 the state of hire, 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
Position is not eligible for sponsorship now or in the future

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