[Hiring] RN Medical Reviewer II @BlueCross BlueShield of South Carolina

Role Description

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.

Logistics:

• Palmetto GBA – one of BlueCross BlueShield’s South Carolina subsidiary companies.
• Location: This position is full-time salaried position Monday-Friday in a typical home office environment. You will work an 8-hour shift scheduled during our normal business hours of 8:00AM-5:00PM ET. It may be necessary, given the business need, to occasionally work additional hours.
• You must have high-speed (non-satellite) internet service and a private home office to work from home.
• Training classes will start on 10/12/2026. Unfortunately, no time off during training will be permitted.
• Preferred candidates will live in South Carolina or Alabama.

What You'll Do:

• 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, and correct coding for claims/operations.
• Make reasonable payment determinations based on clinical medical information and established criteria/protocol sets or clinical guidelines.
• Determine medical necessity, appropriateness, and/or reasonableness and necessity for coverage and reimbursement.
• Monitor process’s timeliness in accordance with contractor standards.
• Document medical rationale to justify payment or denial of services and/or supplies.
• Educate internal and external staff regarding medical reviews, medical terminology, coverage determinations, coding procedures, etc. in accordance with contractor guidelines.
• Participate in quality control activities supporting corporate and team-based objectives.
• Provide guidance, direction, and input as needed to LPN team members.
• Provide education to non-medical staff through discussions, team meetings, classroom participation, and feedback.
• Assist with special projects and specialty duties and responsibilities as assigned by management.

Qualifications

• License: Active RN licensure in state hired, OR, active compact multistate RN license as defined by the Nurse Licensure Compact (NLC).
• Education: Associate degree - Nursing OR Graduate of an accredited School of Nursing.
• Work Experience: Two years of clinical experience as an RN.
• Skills and Abilities:
  • 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.
• Software and Tools: Microsoft Office.

Requirements

• Work Experience: Five years of varied RN nursing experience to include: Medical/Utilization Review, Quality Assurance, Emergency, Critical Care, or Medical/Surgical experience, strongly preferred.
• Medicare or claims experience a plus.
• Software and Tools: Ability to use multiple Windows-based programs simultaneously.

Benefits

• Subsidized health plans, dental and vision coverage.
• 401k retirement savings plan with company match.
• Life Insurance.
• Paid Time Off (PTO).
• On-site cafeterias and fitness centers in major locations.
• Education Assistance.
• Service Recognition.
• National discounts to movies, theaters, zoos, theme parks and more.