Medical Reviewer II

BlueCross BlueShield of South Carolina•W@H South Carolina, SC

4d•Remote

About The Position

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. Centers for Medicare and Medicaid Services (CMS) Requirements: Certain divisions within BlueCross BlueShield of South Carolina require CMS (Centers for Medicare and Medicaid Services) residency that requires employees to have lived in the US for at least three (3) out of the last five (5) years. This is a business requirement – government contracts, not an HR requirement. In the spirit of transparency, if we extend an offer and discover during the background check process that you have not been in the US for at least three (3) years, you will fail background, and the offer will be rescinded. 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. Six-week paid training class with one week of onsite training and five weeks of remote training. One week of onsite training in Columbia, SC, or Birmingham, AL. Training classes will start on 4/27/2026. Unfortunately, no time off during training will be permitted. Preferred candidates will live in South Carolina or Alabama.

Requirements

Active RN licensure in state hired, OR, active compact multistate RN license as defined by the Nurse Licensure Compact (NLC).
Associate degree - Nursing OR Graduate of an accredited School of Nursing.
Two years of clinical experience as an RN.
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.
Microsoft Office.

Nice To Haves

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.
Ability to use multiple Windows-based programs simultaneously.

Responsibilities

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.
Determines 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.