Job Closed
This listing is no longer active.
Providing healthcare administration services and technology solutions for government and corporate entities.
RN Medical Reviewer III
Location
South Carolina
Posted
11 days ago
Salary
0
Seniority
Senior
Job Description
RN Medical Reviewer III
Palmetto GBA
• Performs medical reviews using clinical/medical information provided by physicians/providers and established criteria/protocol sets or clinical guidelines • Documents decisions using indicated protocol sets or clinical guidelines • Provides support and review of medical claims and utilization practices • 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
Job Requirements
- Associate Degree Nursing, OR Four year degree in health-related field, OR Graduate of accredited School of Nursing
- Two years clinical experience plus two years utilization/medical review, quality assurance, or home health experience
- 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
- 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), OR, current active, unrestricted licensure/certification from the United States and in the state of hire in specialty area as required by hiring division/area
Benefits
- Professional development opportunities
- Awards and financial incentives
Related Guides
Related Categories
Related Job Pages
More Medical Reviewer Jobs
Physician, Medical Case Reviewer
Simsy VenturesA builder, an institutional co-founder & a partner from ideas to new startups, ventures & beyond 🚀
• Conduct objective medical case reviews using standardized assessment criteria • Evaluate the timeliness and appropriateness of care provided • Identify quality improvement opportunities • Review cases initiated for non-standardized performance improvement reasons • Assess medical decision-making and compliance with best practices • Provide expert medical opinions • Analyze complex clinical scenarios from an impartial, evidence-based perspective
Medical Reviewer
Cohere HealthCohere Health is a Software-as-a-Service (SaaS) company focused on improving the patient journey by enhancing the quality of care at lower costs, as well as emp
Role Description We are looking for an orthopedic spine Physician Assistant to help deliver on Cohere’s musculoskeletal and orthopedic programs by determining the medical appropriateness of services by reviewing clinical information and applying evidence-based guidelines. The physician assistant should have previous experience in managing spine conditions in an office setting as well as assisting on spine cases in the operating room. This is a remote-first role that may require travel to Boston, MA for new hire onboarding and occasional in-person team meetings and company events. What you’ll do: - Provide timely medical reviews that meet Cohere’s stringent quality parameters - Provide clinical determinations based on evidence-based criteria while utilizing clinical acumen - Clearly and accurately document all communication and decision-making in Cohere workflow tools, ensuring a member and provider can easily reference and understand your decision - Use correct templates for documenting decisions during case review - Meet the appropriate turn-around times for clinical reviews - Demonstrate the highest level of professionalism, accountability, and service in your interactions with Cohere teammates and providers - Support projects specific to building the team's clinical expertise and efficiency, as delegated - Support the team on operational improvements and member/provider experience involving clinical review tasks, as delegated - Clearly communicate with team members Qualifications - Graduate of an accredited Physician Assistant program - Current NCCPA certification (PA-C) and active, unrestricted Physician Assistant license in at least one U.S. state - 3+ years of clinical experience supporting orthopedic spine surgeons and/or neurosurgeons treating spine conditions - Utilization management, prior authorization, or medical review experience a plus - Membership in organizations such as the AAPA or specialty spine organizations Benefits - Fully remote opportunity with about 5% travel - Medical, dental, vision, life, disability insurance, and Employee Assistance Program - 401K retirement plan with company match; flexible spending and health savings account - Flex Time Off + company holidays - Up to 14 weeks of paid parental leave - Pet insurance The salary range for this position is $120,000 to $135,000 annually; as part of a total benefits package which includes health insurance, 401k and bonus. In accordance with state applicable laws, Cohere is required to provide a reasonable estimate of the compensation range for this role. Individual pay decisions are ultimately based on a number of factors, including but not limited to qualifications for the role, experience level, skillset, and internal alignment. Interview Process - Connect with Talent Acquisition for a Preliminary Phone Screening - Meet your Hiring Manager! - Behavioral Interview(s) Company Description Cohere Health’s clinical intelligence platform and agentic AI-powered solutions connect health plans’ strategic goals and providers’ needs, optimizing the speed, cost, and quality of care. With an enterprise approach that streamlines payer-provider decision-making across the care continuum–including policy, prior authorization, payment accuracy, and more–the company improves collaboration and reduces burden, resulting in up to 8x ROI and 94% provider satisfaction. Cohere Health’s innovations continue to receive industry wide recognition. We’ve been named to the 2025 Inc. 5000 list and in the Gartner® Hype Cycle™ for U.S. Healthcare Payers (2022-2025), and ranked as a Top 5 LinkedIn™ Startup for 2023 & 2024. The Coherenauts, as we call ourselves, who succeed here are empathetic teammates who are candid, kind, caring, and embody our core values and principles. We believe that diverse, inclusive teams make the most impactful work. Cohere is deeply invested in ensuring that we have a supportive, growth-oriented environment that works for everyone. We can’t wait to learn more about you and meet you at Cohere Health! Cohere Health is an Equal Opportunity Employer. We are committed to fostering an environment of mutual respect where equal employment opportunities are available to all. To us, it’s personal.
Board Certified Disability Peer Physician Reviewer – Medical Oncology
Dane StreetNational Provider of IME and Medical Peer Review Services
• Evaluate and review disability claims • Conduct reviews from the convenience of home • Participate in a flexible scheduling environment
Medical Advisory Reviewer – Orthopedic Surgery
Dane StreetNational Provider of IME and Medical Peer Review Services
- Apply your expertise to conduct comprehensive reviews of clinical cases - Provide objective, evidence-based medical opinions - Review medical records and prepare clear and concise clinical summaries - Respond to specific questions from clients related to Orthopedic Surgery care



