RN Medical Reviewer II

033 Palmetto GBA; South Carolina; Hybrid; USD 65,000 - 90,000; Full time

Benefits offered by this job

Health coverage

401k match

Life Insurance

Paid Time Off

Education assistance

National discounts

Job summary

033 Palmetto GBA is seeking an experienced RN reviewer to evaluate home health and hospice documentation from providers. You will determine medical necessity and ensure compliance with program guidelines in a fully remote, full-time role.

Ideal candidates have at least two years of clinical nursing experience and an active RN license (state or compact). Proficiency with Microsoft Office and strong communication are essential for success.

Qualifications

• Two years of clinical nursing experience.
• Active RN licensure in state hired or compact multistate license.
• Proficient in Microsoft Office; strong written and verbal communication.
• Ability to work independently, prioritize, and maintain discretion with sensitive information.
• Experience with home health/hospice documentation is preferred.

Responsibilities

• Reviews medical claims and utilization for home health and hospice services.
• Determines medical necessity and coverage appropriateness using guidelines.
• Documents medical rationale for payments or denials.
• Educates staff on reviews, terminology, and coding procedures.
• Supports quality control and participates in special projects.

Skills

RN licensure

Clinical experience

Word processing

Independent work

Customer service

Communication skills

Education

Associate Degree in Nursing

Nursing diploma/BSN acceptable

Tools

Microsoft Office

Job description

Summary

Summary 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.

Why You Should Join Us

Other companies come and go, but we’ve been part of the national landscape for more than seven decades, with our roots firmly embedded in the South Carolina community. We are the largest insurance company in South Carolina … and much more. We are one of the nation’s leading administrators of government contracts. We operate one of the most sophisticated data processing centers in the Southeast. We also have a diverse family of subsidiary companies, allowing us to build on various business strengths. We deliver outstanding service to our customers. If you are dedicated to the same philosophy, consider joining our team!

In this role, you will review home health and hospice documentation submitted by providers to make sure it meets all program requirements, such as the face‑to‑face encounter, plan of care, and supporting clinical documentation. This is a great opportunity for nurses who thrive in high‑intensity clinical settings and are ready to put that expertise to work in a supportive, work‑from‑home environment.

Position Purpose

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 and Location

Logistics: Palmetto GBA one of BlueCross BlueShield of South Carolina’s subsidiary companies. Location: This position is full‑time (40 hours/week), Monday–Friday, and is Work at Home (W@H). To work from home, you must have high‑speed (non‑satellite) internet service and a private home office. Training lasts approximately 4 weeks, 8:00 AM–4:30 PM Eastern Time. After training, associates may set their core hours within our business hours of 6:00 AM–7:00 PM Eastern Time.

Sponsorship

This position is not eligible for sponsorship now or in the future.

What You’ll Do

• Performs 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, correct coding for claims/operations.
• Makes reasonable charge payment determinations based on clinical/medical information and established criteria/protocol sets or clinical guidelines.
• Determines medical necessity and appropriateness and/or reasonableness and necessity for coverage and reimbursement.
• Monitors process’s timeliness in accordance with contractor standards.
• Documents medical rationale to justify payment or denial of services and/or supplies.
• Educates internal/external staff regarding medical reviews, medical terminology, coverage determinations, coding procedures, etc. in accordance with contractor guidelines.
• Participates in quality control activities in support of the corporate and team‑based 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 projects and specialty duties/responsibilities as assigned by management.

To qualify for this Position, you’ll need the following:

• Required Education: Associate Degree – Nursing, OR Graduate of an accredited School of Nursing
• Required Work Experience: Two years clinical experience.
• Required Skills and Abilities: Working knowledge of word processing software. Ability to work independently, prioritize effectively, and make sound decisions. 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.
• Required Software and Tools: Microsoft Office
• Required Licenses and Certificates: Active RN licensure in state hired, OR active compact multistate RN license as defined by the Nurse Licensure Compact (NLC).
• We Prefer That You Have The Following: Critical care experience in a high‑intensity setting such as ER or ICU Home health and/or hospice experience Familiarity with home health and hospice documentation requirements, such as face‑to‑face encounters and plans of care

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

What We Can Do for You

We strive to be an employer where employees across all spectrums have the opportunity to develop their skills, advance their careers and contribute their unique abilities to the growth of our company.

Equal Employment Opportunity Statement

BlueCross BlueShield of South Carolina and our subsidiary companies maintain a continuing policy of nondiscrimination in employment to promote employment opportunities for persons regardless of age, race, color, national origin, sex, religion, veteran status, disability, weight, sexual orientation, gender identity, genetic information or any other legally protected status. Additionally, as a federal contractor, the company maintains affirmative action programs to promote employment opportunities for individuals with disabilities and protected veterans. It is our policy to provide equal opportunities in all phases of the employment process and to comply with applicable federal, state and local laws and regulations. We are committed to working with and providing reasonable accommodations to individuals with disabilities, pregnant individuals, individuals with pregnancy‑related conditions, and individuals needing accommodations for sincerely held religious beliefs, provided that those accommodations do not impose an undue hardship on the Company. We participate in E‑Verify and comply with the Pay Transparency Nondiscrimination Provision. We are an Equal Opportunity Employer.