RN Medical Reviewer III - Reporting and Research

March 14

🏈 Alabama – Remote

Although this job is listed in Alabama, this company may be open to hiring remote in other states.

🌲 North Carolina – Remote

Although this job is listed in North Carolina, this company may be open to hiring remote in other states.

+2 more states

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

⏰ Full Time

🟡 Mid-level

🟠 Senior

🔍🏥 Medical Reviewer

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Palmetto GBA

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Palmetto GBA is one of the nation’s largest providers of high volume claims and transaction processing, as well as contact center operations and technical services to the federal government and commercial customers. With a strong focus on Medicare services, they also offer administrative services, data analytics, and web development solutions, aiming to improve efficiency and value across various transactions.

Enterprise Technologies • Contact Center Operations • Training and Development • Healthcare Policy • Finance and Accounting

1001 - 5000 employees

Founded 1965

🤝 B2B

⚕️ Healthcare Insurance

🏛️ Government

📋 Description

• Performs medical claim reviews for one or more of the following: claims for medically complex services, services that require preauthorization/predetermination, requests for appeal or reconsideration, referrals for potential fraud and/or abuse, and correct coding for claims/operations. • Makes reasonable charge payment determinations based on clinical/medical information and established criteria/protocol sets or clinical guidelines. • Determines medical necessity and appropriateness and/or reasonableness and necessity for coverage and reimbursement. • Documents medical rationale to justify payment or denial of services and/or supplies. • Educates internal/external staff regarding medical reviews, medical terminology, coverage determinations, coding procedures, etc. in accordance with contractor guidelines. • Participates in quality control activities in support of the corporate and team-based objectives. • Provides guidance, direction, and input as needed to LPN team members. • Provides education to non-medical staff through discussions, team meetings, classroom participation and feedback. • Assists with special projects and specialty duties/responsibilities as assigned by Management.

🎯 Requirements

• Required License and Certificate: Active, unrestricted RN licensure from the United States and in the state of hire. • Required Education: Associate degree Nursing, OR, bachelor's degree in health-related field, OR, master's degree in occupational therapy or physical therapy, OR Graduate of accredited School of Nursing. • Required Experience: Two years clinical experience plus two years utilization/medical review, quality assurance, or home health experience. • 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 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. • Ability to persuade, negotiate, or influence others. • Analytical or critical thinking skills. • Ability to handle confidential or sensitive information with discretion.

🏖️ Benefits

• 401(k) retirement savings plan with company match. • Subsidized health plans and free vision coverage. • Life insurance. • Paid annual leave – the longer you work here, the more you earn. • Nine paid holidays. • On-site cafeterias and fitness centers in major locations. • Wellness programs and healthy lifestyle premium discount. • Tuition assistance. • Service recognition. • Incentive Plan. • Merit Plan. • Continuing education funds for additional certifications and certification renewal.