Medical Reviewer I

Palmetto GBA

Medical Reviewer I evaluating medical records to determine necessity for US military members and their families. Documenting decisions and reviewing medical claims as a part of a solid company.

Posted 4/16/2026full-timeRemote • South Carolina • 🇺🇸 United StatesJuniorMid-LevelWebsite

About the role

Key responsibilities & impact

Evaluate the medical records to determine medical necessity and perform utilization management of professional, inpatient, outpatient facility benefits or services and appeals
Document decisions using indicated protocol sets, or clinical guidelines
Provide support and review of medical claims and utilization practices
Perform medical claim reviews and makes a reasonable charge payment determination
Monitor process's timeliness in accordance with contractor standards
Perform authorization process, ensuring coverage for appropriate medical services within benefit and medical necessity guidelines
Utilize allocated resources to back up review determination
Conduct research necessary to make thorough/accurate basis for each determination made
Educate internal/external staff regarding medical reviews, medical terminology, coverage determinations, coding procedures, etc. in accordance with contractor guidelines

Requirements

What you’ll need

Bachelor's degree - Social Work, OR, Graduate of an Accredited School of Licensed Practical Nursing or Licensed Vocational Nursing
2 years clinical experience
Working knowledge of word processing software
Good judgment skills
Demonstrated customer service and organizational skills
Demonstrated proficiency in spelling, punctuation, and grammar skills
Analytical or critical thinking skills
Ability to handle confidential or sensitive information with discretion
Ability to remain in a stationary position and operate a computer
Active, unrestricted LPN/LVN licensure from the United States and in the state of hired, OR, active compact multistate unrestricted LPN license as defined by the Nurse Licensure Compact (NLC), OR, active, unrestricted LBSW (Licensed Bachelor of Social Work) licensure from the United States and in the state of hire

Benefits

Comp & perks

Subsidized health plans
Dental and vision coverage
401k retirement savings plan with company match
Life Insurance
Paid Time Off (PTO)
On-site cafeterias and fitness centers in major locations
Education Assistance
Service Recognition
National discounts to movies, theaters, zoos, theme parks and more

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills & Tools

medical record evaluationutilization managementmedical claims reviewauthorization processcoding proceduresclinical guidelinesanalytical skillscritical thinking

Soft Skills

good judgmentcustomer serviceorganizational skillsdiscretioncommunication skills

Certifications

LPN licenseLVN licenseLBSW licensure