South Carolina Licensed Medical Reviewer

Working remotely in a full-time capacity, the South Carolina Licensed Medical Reviewer will perform medical reviews of claims, determine medical necessity, and document decisions based on clinical guidelines. Key responsibilities: Conduct medical claim reviews for complex services and preauthorization requests Make payment determinations based on clinical information and established criteria Educate internal and external staff on medical reviews and coverage determinations Required qualifications: Associate's degree in a job-related field or a graduate of an accredited School of Nursing Active RN licensure in South Carolina or a compact multistate RN license Two years of clinical experience Proficiency in Microsoft Office Ability to work independently and make sound decisions