PME has an opportunity for nursing candidates in Columbia, SC!
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.
Position Responsibilities include:
- 70% 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.
- 20% Educates internal/external staff regarding medical reviews, medical terminology, coverage determinations, coding procedures, etc. in accordance with contractor guidelines.
- 10% 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.
Pay Rate: 30.00/hour
Monday-Friday: 7:30am-4pm
Must live in South Carolina and possess valid RN license
Candidate can transition to remote work after initial 8 weeks of training
Requirements
- Bachelor's Degree in Nursing or related field (Required)
- 2 years clinical experience PLUS 1 year of utilization and medical review (Required)
- Proficient knowledge of Microsoft Office, including Excel and Outlook (Required)
- Experience handling confidential or sensitive information (Required)
- 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 (Required)