Medical Reviewer II

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🔥 14 minutes ago

🏈 Alabama, South Carolina – Remote

🏈 Alabama – Remote 🌴 South Carolina – Remote

⏰ Full Time

🟢 Junior

🟡 Mid-level

🔍🏥 Medical Reviewer

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Palmetto GBA

WebsiteLinkedInAll Job Openings

1001 - 5000 employees

Founded 1965

⚕️ Healthcare Insurance

🏛️ Government

🤝 B2B

Healthcare Insurance • Government • B2B

Palmetto GBA is one of the nation's largest providers of high-volume Medicare claims and transaction processing, contact center operations, and technical services for federal healthcare programs and commercial customers. The company serves as a Medicare Administrative Contractor (MAC) and supports enrollment, claims adjudication, provider and beneficiary services, specialized programs (e. g. , DMEPOS, Home Health & Hospice, Railroad Medicare), pricing and coding analysis, and third-party administrator functions. Headquartered in Columbia, South Carolina, Palmetto GBA operates across multiple Medicare jurisdictions and is part of the Celerian Group.

📋 Description

• Perform medical claim reviews for one or more of the following: claims for medically complex services, services that require preauthorization/predetermination, requests for appeal or reconsideration, referrals for potential fraud and/or abuse, and correct coding for claims/operations • Make reasonable payment determinations based on clinical medical information and established criteria/protocol sets or clinical guidelines • Determine medical necessity, appropriateness, and/or reasonableness and necessity for coverage and reimbursement • Monitor process’s timeliness in accordance with contractor standards • Document medical rationale to justify payment or denial of services and/or supplies • Educate internal and external staff regarding medical reviews, medical terminology, coverage determinations, coding procedures, etc. in accordance with contractor guidelines • Participate in quality control activities supporting corporate and team-based objectives • Provide guidance, direction, and input as needed to LPN team members • Provide education to non-medical staff through discussions, team meetings, classroom participation, and feedback • Assist with special projects and specialty duties and responsibilities as assigned by management

🎯 Requirements

• Active RN licensure in state hired, OR, active compact multistate RN license as defined by the Nurse Licensure Compact (NLC) • Associate degree - 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

🏖️ Benefits

• 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