RN Medical Reviewer II (DME) - CGS

About the position Responsibilities • Perform medical claim reviews for complex services and preauthorization requests. • Make payment determinations based on clinical information and established criteria. • Determine medical necessity and appropriateness for coverage and reimbursement. • Monitor process timeliness in accordance with contractor standards. • Document medical rationale for payment or denial of services. • Educate internal and external staff on medical reviews and coding procedures. • Participate in quality control activities to support corporate objectives. • Provide guidance and input to LPN team members. • Assist with special projects and responsibilities as assigned. Requirements • Active, unrestricted RN licensure from the United States or a compact multistate RN license. • Associates degree in a job-related field or graduate of an accredited school of nursing. • Two years of clinical nursing experience. • Working knowledge of word processing software. • Ability to work independently and prioritize effectively. • Good judgment and decision-making skills. • Demonstrated customer service and organizational skills. • Strong oral and written communication skills. • Analytical or critical thinking skills. • Ability to handle confidential information with discretion. • Proficiency in Microsoft Office. Nice-to-haves • One year of Medical Review experience. • Experience with Durable Medical Equipment (DME). • Administrative experience in Health Care Quality Assurance, Medical Insurance, Utilization Review, or Case Management. • Five years of clinical experience as a Registered Nurse. Benefits • 401(k) retirement savings plan with company match. • Subsidized health plans and free vision coverage. • Life insurance. • Paid annual leave that increases with tenure. • Nine paid holidays. • On-site cafeterias and fitness centers in major locations. • Wellness programs and healthy lifestyle premium discount. • Tuition assistance. • Service recognition. • Incentive Plan. • Merit Plan. • Continuing education funds for certifications. Apply tot his job Apply To this Job