Job Description

Job Description

Job Description

Must live within South Carolina.
Must be willing to work on site the first 1-2 weeks for training, then would be fully remote
Must have an active LPN License in the state of South Carolina
Job at a Glance

Title: Medical Claims Reviewer
Location: SC (preferably within SC)
Pay: $23.00 /hour

This role involves performing medical reviews using established criteria and managing utilization of professional, inpatient, or outpatient services. The position supports medical claims and utilization practices, with onsite training for the first two weeks followed by work from home.

• Perform medical claim reviews and make reasonable charge payment determinations.
• Monitor process timeliness in accordance with contractor standards.
• Conduct authorization processes ensuring coverage for appropriate medical services within benefit and medical necessity guidelines.
• Review interdepartmental requests and medical information to complete utilization processes efficiently.
• Conduct high dollar forecasting research and formulate patient health summaries with future prognosis and projected costs.
• Perform screenings and assessments to determine risk via telephone.
• Review and determine eligibility, level of benefits, and medical necessity of services.
• Provide education to members and their families/caregivers.
• Review first-level appeals, ensuring thorough documentation and basis for each determination.
• Conduct research to support accurate and thorough decision-making.

• Clinical LPN expereince 
• Working knowledge of word processing software.
• Good judgment skills.
• Demonstrated customer service and organizational skills.
• Proficiency in spelling, punctuation, and grammar.
• Analytical or critical thinking skills.
• Ability to handle confidential or sensitive information with discretion.
• Ability to remain stationary and operate a computer.

• Working knowledge of spreadsheet and database software.
• Demonstrated oral and written communication skills.
• Ability to persuade, negotiate, or influence others.
• Knowledge of Microsoft Excel, Access, or other spreadsheet/database software.

As a trusted technology partner, CEI delivers solutions that help our customers transform their business and achieve meaningful results. From strategy and custom application development through application management - our technology and digital experience services are tailored to meet each unique need of our customers. Our staffing solutions bring specialized skills to complement our customers' workforce and project requirements.

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