Reviewer II, Medical

Job not on LinkedIn

🕒 July 15

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

🏈 Alabama – Remote 🌲 North Carolina – Remote 🌴 South Carolina – Remote

⏰ Full Time

🟢 Junior

🟡 Mid-level

🦅 H1B Visa Sponsor

This company has sponsored H1B visas in the past.

👻 Ghost score 32%

What it means: how likely this posting is sitting open without active hiring.How to read it: 60% or higher means we think this is a ghost. Lower scores are less of a worry.How we score it: age, reposts, open roles vs team size, how fast jobs close, and whether pay is listed.Fine print: an estimate from public data, not a judgment of the company. Real jobs can score high, so treat it as a hint, not a fact.

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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, services requiring preauthorization/predetermination, appeals or reconsiderations, potential fraud and/or abuse referrals, and correct coding • Make charge payment determinations based on 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 in accordance with contractor standards • Document medical rationale supporting payment or denial of services and/or supplies • Educate internal and external staff regarding 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

• Associate's in a job related field • Graduate of Accredited School of Nursing • Active RN licensure in state hired, OR active compact multistate RN license as defined by the Nurse Licensure Compact (NLC) • 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 • Full-time availability, 40 hours/week, Monday through Friday • Remote work eligibility in South Carolina, Georgia, North Carolina, or Alabama

🏖️ Benefits

• 401(k) retirement savings plan with company match • Subsidized health plans, dental and vision coverage • Life insurance • Paid Time Off (PTO) • Nine paid holidays • On-site cafeterias and fitness centers in significant locations • Wellness programs and a healthy lifestyle premium discount • Tuition assistance • Service Recognition