Remote RN Medical Reviewer II — Claims & Denials

033 Palmetto GBA; South Carolina; Hybrid; USD 70,000 - 90,000; Full time

Benefits offered by this job

401(k) retirement savings plan with  $

Subsidized health plans

Life insurance

Paid Time Off (PTO)

Nine paid holidays

Tuition assistance

Service Recognition

Job summary

BlueCross BlueShield of South Carolina is seeking a full‑time medical review professional. You will assess claims for complex services, preauthorization requests and potential fraud using established guidelines.

You will document rationale and educate staff while supporting quality control and projects. The role requires an RN license in the hiring state (or compact multistate), an associate degree or nursing equivalency, and at least two years of clinical experience, with strong communication

Qualifications

• Associate’s in a job related field.
• Graduate of Accredited School of Nursing.
• Active RN licensure in state hired or compact multistate license.
• 2 years clinical experience.

Responsibilities

• Perform medical claim reviews based on criteria and guidelines.
• Determine medical necessity and reasonableness for coverage.
• Educate staff on medical reviews and coding procedures.
• Document medical rationale for payments or denials.
• Support quality control and participate in special projects.

Skills

Word processing

Independent work

Decision making

Customer service

Communication skills

Analytical thinking

Discretion with confidential info

Education

Associate degree

Nursing degree equivalency

Tools

Microsoft Office

Job description

BlueCross BlueShield of South Carolina is seeking a full‑time medical review professional. You will assess claims for complex services, preauthorization requests and potential fraud using established guidelines.

You will document rationale and educate staff while supporting quality control and projects. The role requires an RN license in the hiring state (or compact multistate), an associate degree or nursing equivalency, and at least two years of clinical experience, with strong communication