Senior Medical Reviewer

Job not on LinkedIn

🕒 6 days ago

🌴 South Carolina – Remote

🌴 South Carolina – Remote

⏰ Full Time

🟠 Senior

🔍🏥 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

• Acts as Team Lead for specialty programs, medical review, utilization management, and case management areas by providing assistance and support to unit supervisor/manager by giving direction/guidance/training to staff. • Ensures appropriate levels of healthcare services are provided. • Functions as a team leader/senior-level Medical Reviewer. • Provides leadership/guidance/direction/training to staff. • Maintains a working knowledge of unit functions and the ability to interpret to new hires, department interworking, and workflow. • Acts as a resource for staff/external entities troubleshooting as well as resolving issues. • Keeps manager informed of any problems/issues that need resolving. • Assists management with monitoring workflow and workloads (including reassignment of work to meet timelines, redirecting work intake source to balance workloads), reporting, and addressing aging issues. • Participates in departmental quality reviews. • Follows a process to ensure quality plan is adhered to and communicated to all parties. • Gives/receives feedback regarding medical review decision making and technical claims processing issues. • Ensures that quality work instructions/forms/documents are developed/revised as needed.

🎯 Requirements

• Required Education: Associate Degree - Nursing OR Graduate of Accredited School of Nursing. • Required Work Experience: Four years of clinical, OR Two years of clinical and two years of medical review/utilization review, OR Combination of health plan, clinical, and business experience totaling four years. • Preferred requirements: ESRD/renal dialysis experience; Five or more years’ clinical, quality management, or leadership experience as a registered nurse in a Dialysis setting; Three or more years’ education/training/consulting experience related to Dialysis services (may be concurrent); Three or more years’ experience in quality management coordination related to Dialysis services (may be concurrent). • Required Skills and Abilities: Working knowledge of managed care and various forms of health care delivery systems; Strong clinical experience to include home health, rehabilitation, and/or broad medical surgical experience; Knowledge of specific criteria/protocol sets and the use of the same; Working knowledge of word processing and spreadsheet software; Ability to work independently, prioritize effectively, and make sound decisions; Good judgment skills; Demonstrated customer service, organizational, and presentation skills; Demonstrated proficiency in spelling, punctuation, and grammar skills; Demonstrated oral and written communication skills; Ability to persuade, negotiate, or influence others; Analytical or critical thinking skills; Ability to handle confidential or sensitive information with discretion; Ability to lead/direct/motivate others. • Required Software and Tools: Microsoft Office. • Required License and Certificate: Active, unrestricted RN licensure from the United States and in the state of hire, OR, active compact multistate unrestricted RN license as defined by the Nurse Licensure Compact NLC.

🏖️ Benefits

• Provides quality service and communicates effectively with external/internal customers in response to inquiries. • Obtains information from internal departments, providers, government, and/or private agencies, etc. to resolve discrepancies/problems. • Participates in compliance initiatives and other directed activities. • Participates/oversees special projects as requested by management.