South Carolina Licensed RN Medical Reviewer

A company is looking for a RN Medical Reviewer III to perform medical reviews and support medical claims and utilization practices. Key Responsibilities Conducts medical claim reviews and determines medical necessity based on clinical information and established guidelines Educates staff on medical reviews, terminology, and coverage determinations Participates in quality control activities and provides guidance to team members Required Qualifications Graduate of an accredited School of Nursing or an Associate's degree in a related field 2 years of clinical experience plus 1 year in utilization/medical review, or 3 years of clinical experience Working knowledge of managed care and health care delivery systems Active unrestricted RN licensure in the United States and state of hire Proficiency in Microsoft Office and ability to handle confidential information

Mar 10, 2025 - 20:12

A company is looking for a RN Medical Reviewer III to perform medical reviews and support medical claims and utilization practices. Key Responsibilities Conducts medical claim reviews and determines medical necessity based on clinical information and established guidelines Educates staff on medical reviews, terminology, and coverage determinations Participates in quality control activities and provides guidance to team members Required Qualifications Graduate of an accredited School of Nursing or an Associate's degree in a related field 2 years of clinical experience plus 1 year in utilization/medical review, or 3 years of clinical experience Working knowledge of managed care and health care delivery systems Active unrestricted RN licensure in the United States and state of hire Proficiency in Microsoft Office and ability to handle confidential information