RN Medical Reviewer II Palmetto GBA

About the position Palmetto GBA is seeking dedicated Registered Nurses to join our RCD (Review Choice Demonstration) Medicare Medical Review team. In this administrative role, selected candidates will be responsible for reviewing medical records to assess medical necessity and eligibility in accordance with RCD guidelines. This position is ideal for individuals looking to transition from direct patient care to a work-from-home environment, as it involves no regular patient or provider contact. Candidates will undergo a comprehensive six-week training program, which will commence on October 28, 2024, and will take place in either Columbia, SC, or Birmingham, AL. During this training period, no time off will be permitted, and candidates must have high-speed internet service and a private home office to facilitate remote work after training. The regular work hours for this position are from 8:00 am to 5:00 pm, Monday through Friday. Preferred candidates will reside in South Carolina or Alabama. The role involves performing medical claim reviews for various services, including medically complex services, preauthorization requests, appeals, and coding accuracy. The RN Medical Reviewer will make informed payment determinations based on clinical information and established guidelines, ensuring that all decisions regarding medical necessity and appropriateness for coverage and reimbursement are well-documented. Additionally, the role includes educating both internal and external staff on medical reviews, terminology, and coding procedures, as well as participating in quality control activities to support corporate objectives. The RN will also provide guidance to LPN team members and assist with special projects as assigned by management. Responsibilities • Perform medical claim reviews for complex services and preauthorization requests. , • Make payment determinations based on clinical medical information and established criteria. , • Determine medical necessity and appropriateness for coverage and reimbursement. , • Monitor process timeliness in accordance with contractor standards. , • Document medical rationale to justify payment or denial of services. , • Educate internal and external staff regarding medical reviews and coding procedures. , • Participate in quality control activities supporting corporate objectives. , • Provide guidance and input to LPN team members. , • Assist with special projects and responsibilities as assigned by management. Requirements • Active RN licensure in the state hired or active compact multistate RN license as defined by the Nurse Licensure Compact (NLC). , • Associate degree in Nursing or graduate of an accredited School of Nursing. , • Two years of clinical experience as an RN. , • Working knowledge of word processing software. , • Ability to work independently and prioritize effectively. , • Good judgment and decision-making skills. , • Demonstrated customer service and organizational skills. , • Strong oral and written communication skills. , • Analytical or critical thinking skills. , • Ability to handle confidential information with discretion. , • Proficiency in Microsoft Office. Nice-to-haves • Medical review or utilization review experience is strongly preferred. , • Five years of varied RN nursing experience including Emergency, Critical Care, or Medical/Surgical experience. , • Experience with Medicare. , • Ability to use multiple Windows-based programs simultaneously. Benefits • 401(k) retirement savings plan with company match , • Health plans and free vision coverage , • Life insurance , • Paid annual leave that increases with tenure , • Nine paid holidays , • On-site cafeterias and fitness centers in significant locations , • Wellness programs and healthy lifestyle premium discount , • Tuition assistance , • Service Recognition Apply Job!