Medical Reviewer III

Palmetto GBA

. Performs medical reviews using clinical/medical information provided by physicians/providers and established criteria/protocol sets or clinical guidelines .

Posted 5/15/2026full-timeAlabama, North Carolina, South Carolina • 🇺🇸 United StatesMid-LevelSeniorWebsite

About the role

Key responsibilities & impact

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
Participate in quality control activities in support of the corporate and team-based objectives
Perform 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
Make reasonable charge payment determinations based on clinical/medical information and established criteria/protocol sets or clinical guidelines
Document medical rationale to justify payment or denial of services and/or supplies

Requirements

What you’ll need

Associate's in a job related field
Active, unrestricted RN licensure from the United States in the state of hire, OR active compact multistate unrestricted RN license as defined by the Nurse Licensure Compact (NLC)
2 years clinical plus 1 year utilization/medical review, quality assurance, or home health, OR 3 years clinical
Working knowledge of word processing software
Ability to work independently, prioritize effectively, and make sound decisions
Good judgment skills
Demonstrated customer service and organizational skills
Demonstrated oral and written communication skills
Analytical or critical thinking skills
Ability to handle confidential or sensitive information with discretion.

Benefits

Comp & perks

401(k) retirement savings plan with company match
Subsidized health plans, dental and vision coverage
Life insurance
Paid Time Off (PTO)
Nine paid holidays
On-site cafeterias and fitness centers in significant locations
Wellness programs and a healthy lifestyle premium discount
Tuition assistance

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills & Tools

medical reviewsclinical guidelinesmedical claims reviewutilization reviewquality assurancecorrect codingpreauthorizationreconsiderationfraud detection

Soft Skills

independent workprioritizationdecision makinggood judgmentcustomer serviceorganizational skillsoral communicationwritten communicationanalytical skillscritical thinking

Certifications

RN licensureNurse Licensure Compact (NLC)