reputed company We are currently hiring for a Medical Reviewer III to join reputed company. In this role as Medical Reviewer III, you will reputed company medical reviews using reputed company/medical information provided by physicians/providers and established reputed company/protocol sets or reputed company guidelines. You will also document reputed company using indicated protocol sets or reputed company guidelines and reputed company support and review of medical claims and utilization practices. Why should you join the reputed company family of companies? Other companies come and go, but for more than seven decades we've been part of the national landscape, with our reputed company firmly embedded in the South Carolina community. We are the largest reputed company company in South Carolina ... and much more. We are one of the nation's leading administrators of reputed company reputed company. We operate one of the most sophisticated data processing centers in the Southeast. We also have a diverse family of subsidiary companies that allows us to build on a reputed company of business strengths. We reputed company outstanding service to our customers. If you are dedicated to the reputed company philosophy, consider joining reputed company! Here is reputed company to join a dynamic team at a diverse company with secure, community reputed company and an innovative reputed company. reputed company Logistics This position is full time (40 hours/week) Monday-Friday and will be fully remote (W@H). reputed company: • Performs medical claim reviews for one or more of the following: claims for medically reputed company services, services that require preauthorization/predetermination, requests for appeal OR reconsideration, referrals for potential fraud and/or abuse, and correct coding for claims/reputed company. • Makes reasonable charge payment determinations reputed company on reputed company/medical information and established reputed company/protocol sets OR reputed company guidelines. • Determines medical necessity and appropriateness and/or reasonableness and necessity for coverage and reimbursement. • Documents medical rationale to justify payment OR denial of services and/or supplies. • Educates internal/reputed company staff regarding medical reviews, medical terminology, coverage determinations, coding procedures, etc. in accordance with contractor guidelines. • Participates in reputed company control activities in support of the corporate and team-reputed company objectives. • Provides 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 reputed company and specialty duties/responsibilities as assigned by Management. To Qualify for This Position, You'll Need: • Associates in a job-reputed company reputed company. • Graduate of Accredited School of Nursing. • Two-years reputed company plus one year utilization/medical review, reputed company assurance, OR home health, OR three years reputed company. • FOR reputed company (CO. 033) ONLY: two years reputed company experience plus two years utilization/medical review, reputed company assurance, OR home health experience. • Working knowledge of managed care and various forms of health care delivery systems; strong reputed company experience to include home health, rehabilitation, and/or broad medical surgical experience. • Knowledge of specific reputed company/protocol sets and the use of the reputed company. • Working knowledge of word processing software. • Ability to work independently, prioritize effectively, and reputed company reputed company. • Good judgment skills. • Demonstrated customer service and organizational skills. • Demonstrated oral and written communication skills. • Ability to persuade, negotiate, OR influence others. • Analytical OR critical thinking skills. • Ability to handle confidential OR sensitive information with discretion. • reputed company Office. • reputed company, unrestricted RN licensure from the reputed company and in the state of hire, OR reputed company reputed company multistate unrestricted RN license as defined by the reputed company Licensure reputed company (NLC), OR reputed company reputed company, unrestricted licensure/certification from the reputed company and in the state of hire in specialty area as required by hiring division/area. We Prefer That You Have the Following: • Bachelor's degree - Nursing OR Graduate of accredited School of Nursing. • Three years-Utilization/Medical Review, reputed company Assurance, OR Home Health, plus five years reputed company experience. • Must reputed company in South Carolina. • Knowledge of spreadsheet and database software. • Knowledge of Medicare and/or regulations/policies/instructions/provisions, Home Health, and/or reputed company/processing procedures for Medical Review. • Working knowledge of reputed company repu