Reviewer II, Medical

Palmetto GBA

Performs medical claim reviews and documentation using clinical information and established criteria. Supports medical claims and utilization practices in the healthcare sector.

Posted 7/9/2026full-timeRemote • Alabama, North Carolina, South Carolina • 🇺🇸 United StatesJuniorMid-LevelWebsite

About the role

Key responsibilities & impact

Perform medical claim reviews 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
Determine medical necessity and appropriateness and/or reasonableness and necessity for coverage and reimbursement
Monitors process’s timeliness in accordance with contractor standards
Document medical rationale to justify payment or denial of services and/or supplies
Educate internal/external staff regarding medical reviews, medical terminology, coverage determinations, coding procedures, etc.
Participate in quality control activities in support of the corporate and team-based objectives
Provide 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

Requirements

What you’ll need

Associate's in a job related field
Active RN licensure in state hired, OR active compact multistate RN license as defined by the Nurse Licensure Compact (NLC)
2 years clinical experience
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
Service Recognition

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills & Tools

Medical Necessity DeterminationCoding ProceduresPreauthorization ReviewQuality Control ActivitiesDocumentation of Medical Rationale

Soft Skills

Good JudgmentCustomer ServiceOrganizational SkillsAbility to Work IndependentlyPrioritization Skills

Certifications

Associate's Degree in Related FieldActive Compact Multistate RN License