RN Medical Reviewer II

BlueCross and BlueShield of South Carolina; United States; Remote; USD 65,000 - 90,000; Full time

Benefits offered by this job

Subsidized health plans

401k retirement savings plan with comp

Life Insurance

Paid Time Off (PTO)

On-site cafeterias and fitness centers

Education Assistance

Service Recognition

National discounts

Job summary

BlueCross BlueShield of South Carolina is seeking a remote Medical Review Nurse to perform medical claim reviews, determine medical necessity, and support coverage decisions. The role requires an RN license and 2 years of clinical experience, with strong communication and analytical skills.

Work hours are 8:00 a.m.–5:00 p.m. Monday–Friday with occasional overtime. This full-time remote position offers comprehensive benefits and opportunities to impact healthcare utilization.

Qualifications

• Associate's degree in a job-related field.
• Graduate of Accredited School of Nursing.
• Minimum of 2 years clinical experience.
• Proficient in word processing software and Microsoft Office.
• Ability to work independently, prioritize tasks, and make sound decisions.
• Demonstrated judgment, customer service, and organizational skills.
• Strong oral and written communication; analytical thinking.
• Capable of handling confidential information with discretion.

Responsibilities

• Performs medical claim reviews for complex services or preauthorization needs.
• Bases payment determinations on clinical data and established guidelines.
• Determines medical necessity for coverage and reimbursement.
• Monitors timeliness according to contractor standards.
• Documents rationale for payment decisions and denials.
• Educates internal/external staff on medical reviews, coding, and coverage determinations.
• Contributes to quality control and team objectives.
• Provides guidance to LPNs and extracts education for non-medical staff.
• Supports special projects and specialty duties as assigned.

Skills

Word processing

Independent work

Prioritization

Decision making

Customer service

Organizational skills

Oral and written communication

Analytical thinking

Confidential information handling

Education

Associate degree

Nursing degree equivalent

Tools

Microsoft Office

Job description

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.

Description

Why should you join the BlueCross BlueShield of South Carolina family of companies? 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!

Logistics

Palmetto GBA one of BlueCross BlueShield of South Carolina's subsidiary companies.

Location

This a full-time remote position. You will work an 8-hour shift scheduled during our normal business hours of 8:00 a.m.-5:00 p.m. Monday - Friday. It may be necessary, given the business need to work occasional overtime.

Government Clearance

This position requires the ability to obtain a security clearance, which requires applicants to be a U.S. Citizen.

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's in a job-related field.
• Degree Equivalency: Graduate of Accredited School of Nursing.
• Required Work Experience: 2 years clinical experience.
• Required 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.
• 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).

Our Comprehensive Benefits Package Includes the Following:

We offer our employees great benefits and rewards. You will be eligible to participate in the benefits the first of the month following 28 days of employment.

• 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 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 employmen