Role Name: Medical Reviewer II
Location: Columbia, SC 29229
Work Environment: Onsite 
Schedule: Mon - Fri, 8am - 4:30pm.
Contract length: 3 months assignment with possible extension

Job Summary:
Duties/About the role: 
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.

Day to Day:

• 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, 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. Monitors processs timeliness in accordance with contractor standards. 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.

Job Requirements:
Required Education:  Associate Degree - Nursing or Graduate of an accredited School of Nursing.
Required Work Experience: 2 years clinical experience.
Required Training: Active RN licensure in state hired, OR, active compact multistate RN license as defined by the Nurse Licensure Compact (NLC). 

 


At SPECTRAFORCE, we are committed to maintaining a workplace that ensures fair compensation and wage transparency in adherence with all applicable state and local laws. This position’s starting pay is: $29.00/hr.