Medical Reviewer

Simsy Ventures

. Handle claim types including Radiology, Ambulance, Physical Therapy, and Surgical .

Posted 10/8/2026full-timeRemote • United StatesMid-LevelSenior💰 $65,000 per yearWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in medical review processes, including claim handling for Radiology, Ambulance, Physical Therapy, and Surgical services. Proficient in utilizing clinical information and Medicare guidelines to assess medical necessity and coverage determinations.

Highest-signal resume keywords

Active RN LicenseClinical ExperienceUtilization ReviewQuality AssuranceMicrosoft Office Proficiency

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Medical ReviewClaim HandlingCoverage DeterminationCritical ThinkingDocumentationCoding ReviewPreauthorization ReviewFraud DetectionQuality ControlHealth Care Delivery Systems

Soft Skills

Strong CommunicationSound JudgmentIndependent WorkPrioritizationConfidentiality Handling

Certifications & Qualifications

RN LicenseNurse Licensure Compact

Industry Keywords

Medicare GuidelinesManaged CareHome HealthRehabilitationMedical-Surgical Experience

About the role

Key responsibilities & impact

Handle claim types including Radiology, Ambulance, Physical Therapy, and Surgical
Use clinical information, Medicare guidelines, and established criteria to determine medical necessity, coverage, and payment
Document medical review decisions and the rationale supporting payment or denial of services and supplies
Review medically complex claims, preauthorization or predetermination requests, appeals and reconsiderations, potential fraud and abuse referrals, and correct coding reviews
Educate internal and external staff on medical review, terminology, coverage determinations, and coding
Provide guidance and direction to LPN team members as needed
Participate in quality control activities
Assist with special projects and specialty assignments as directed by management

Requirements

What you’ll need

Active, unrestricted RN license in the U.S. and in the state of hire, or an active, unrestricted multistate RN license under the Nurse Licensure Compact
Associate’s degree in nursing or graduate of an accredited school of nursing
2 years of clinical experience plus 2 years in utilization or medical review, quality assurance, or home health
Home health, rehabilitation, and/or broad medical-surgical experience
Working knowledge of criteria and protocol sets, managed care, and health care delivery systems
Proficiency in Microsoft Office
Strong written and verbal communication
Sound judgment and critical thinking
Ability to work independently, prioritize, and handle confidential information
Must be able to pass the CMS background investigation and complete fingerprinting and EUA/system access clearance in a timely manner
Must live within a three hour driving radius of Augusta, GA

Benefits

Comp & perks

401(k) and company match
PTO that grows the longer you stay
Health, Vision, Dental
Company provided Life Insurance and Voluntary Life Insurance
Short Term Disability and Long Term Disability
Comprehensive benefits package