RN Medical Reviewer II

Job not on LinkedIn

🔥 1 minute ago

🌴 South Carolina – Remote

🌴 South Carolina – Remote

⏰ Full Time

🟢 Junior

🟡 Mid-level

🔍🏥 Medical Reviewer

🦅 H1B Visa Sponsor

This company has sponsored H1B visas in the past.

👻 Ghost score 10%

What it means: the chance that no one is really hiring for this job.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

• Review home health and hospice documentation submitted by providers for required program elements, including face-to-face encounters, plans of care, and supporting clinical documentation • Perform medical claim reviews for medically complex services, preauthorization/predetermination requests, appeals or reconsiderations, potential fraud and/or abuse referrals, and coding accuracy • Make charge payment determinations using clinical information and established criteria, protocols, or clinical guidelines • Determine medical necessity, appropriateness, reasonableness, coverage, and reimbursement • Monitor review timeliness according to contractor standards • Document medical rationale supporting payment or denial of services and supplies • Educate internal and external staff on medical reviews, 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

• Associate Degree – Nursing, OR graduate of an accredited School of Nursing • Two years clinical experience • Working knowledge of word processing software • Ability to work independently, prioritize effectively, and make sound decisions • 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 • Active RN licensure in state hired, OR active compact multistate RN license as defined by the Nurse Licensure Compact (NLC) • High-speed, non-satellite internet service and a private home office • Must be able to work full-time, 40 hours/week, Monday–Friday • Position is not eligible for sponsorship now or in the future • Preferred: critical care experience in a high-intensity setting such as ER or ICU • Preferred: home health and/or hospice experience • Preferred: familiarity with home health and hospice documentation requirements, such as face-to-face encounters and plans of care

🏖️ 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 • Reasonable accommodations for disabilities, pregnancy-related conditions, and sincerely held religious beliefs, where applicable

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