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 .

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

Core Competencies

Role fit

Core Competencies

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

Highest-signal resume keywords

Active RN LicensureClinical Experience as an RNMedical/Utilization Review ExperienceMicrosoft Office ProficiencyAnalytical or Critical Thinking Skills

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Medical Claim ReviewPayment DeterminationClinical GuidelinesCoding ProceduresMedical Necessity AssessmentQuality AssuranceDocumentation SkillsCustomer ServiceDecision-MakingConfidential Information Handling

Soft Skills

Good Judgment SkillsOrganizational SkillsOral Communication SkillsWritten Communication SkillsAbility to Work Independently

Tools & Technologies

Word Processing SoftwareWindows-Based ProgramsHigh-Speed Internet Service

Certifications & Qualifications

Active RN LicensureAssociate Degree in Nursing

Industry Keywords

Medically Complex ServicesPreauthorization RequestsReconsiderationsFraud and Abuse ReferralsMedicare Experience

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, coverage, and reimbursement
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, 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 assigned by management
Work Monday-Friday on an 8-hour shift scheduled during 8:00 AM-5:00 PM ET business hours
Complete training beginning 12/7/2026

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
High-speed (non-satellite) internet service
Private home office to work from home
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
Preferred: ability to use multiple Windows-based programs simultaneously
No time off permitted during training

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
Opportunity to develop skills, advance careers and contribute to company growth
Reasonable accommodations for disabilities, pregnancy-related conditions, and sincerely held religious beliefs