Medical Reviewer II

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🏈 Alabama, South Carolina, +1 more states – Remote

🏈 Alabama – Remote 🌴 South Carolina – Remote 🎸 Tennessee – Remote

⏰ Full Time

🟢 Junior

🟡 Mid-level

🔍🏥 Medical Reviewer

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Palmetto GBA

WebsiteLinkedInAll Job Openings

1001 - 5000 employees

Founded 1965

🏥 Healthcare

💼 Consulting

📦 Logistics

Healthcare • Consulting • Logistics

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 medically complex services, preauthorization/predetermination requests, appeals or reconsiderations, potential fraud and/or abuse referrals, and correct coding for claims/operations • 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

🎯 Requirements

• Active RN licensure in the state hired, or active compact multistate RN license under the Nurse Licensure Compact (NLC) • Associate degree in Nursing or graduation from 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 discreetly • Microsoft Office proficiency • Preferred: three years of varied RN nursing experience, including Medical/Utilization Review, Quality Assurance, Emergency, Critical Care, or Medical/Surgical experience • Acute care experience required; critical care and medical/utilization review experience preferred • Medicare or claims experience is a plus • Ability to use multiple Windows-based programs simultaneously • CMS residency requirement: lived in the US for at least three of the last five years • Must maintain a private, quiet home workspace and reliable high-speed internet • Must use a wired Ethernet connection; Wi-Fi, satellite internet, air cards, mobile hotspots, 5G home internet, and BPL are not permitted • Must work an eight-hour shift during normal business hours, Monday-Friday, typically 8:00 AM-5:00 PM ET • No time off permitted during training

🏖️ 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 • Training classes and programs that help employees prepare for leadership positions • Tuition assistance for education advancement • Awards and financial incentives