RN Medical Reviewer II

Job not on LinkedIn

🔥 12 hours ago

🏈 Alabama, North Carolina, +2 more states – Remote

🏈 Alabama – Remote 🌲 North Carolina – Remote 🌴 South Carolina – Remote 🎸 Tennessee – 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: 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, preauthorization/predetermination requests, appeals or reconsiderations, potential fraud and/or abuse referrals, and correct coding claims/operations • Make payment determinations using clinical medical information and established criteria, protocol sets, or clinical guidelines • Determine medical necessity, appropriateness, reasonableness, and coverage/reimbursement necessity • 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 • Work Monday-Friday, an 8-hour shift during normal business hours of 8:00 AM-5:00 PM ET, with occasional additional hours as needed

🎯 Requirements

• Active RN licensure in state hired, OR active compact multistate RN license as defined by 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 with discretion • Microsoft Office proficiency • Ability to use multiple Windows-based programs simultaneously preferred • Five years of varied RN nursing experience, including Medical/Utilization Review, Quality Assurance, Emergency, Critical Care, or Medical/Surgical experience, strongly preferred • Medicare or claims experience a plus • Must have high-speed (non-satellite) internet service and a private home office • CMS residency requirement: lived in the US for at least three of the last five years

🏖️ 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