RN Medical Reviewer II – Claims & Utilization Review

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

Benefits offered by this job

Subsidized health plans

Dental and vision coverage

401k with company match

Life Insurance

PTO

On-site cafeterias and fitness centers

Job summary

Palmetto GBA, a BlueCross BlueShield South Carolina subsidiary, seeks a full-time RN reviewer to evaluate medical claims and utilization requests from home. You will review complex services, ensure medical necessity, and document rationale for payments or denials during a standard 8-hour ET workday.

Ideal candidates hold an RN license, an associate degree or nursing diploma, and at least two years of clinical RN experience. Training and quiet home-office setup required.

Qualifications

• Active RN licensure in state hired or compact multistate licensure.
• Two years of clinical experience as an RN.
• Working knowledge of word processing software; ability to work independently and make sound decisions.
• Good judgment, customer service, organization, and communication skills.
• Analytical or critical thinking abilities; handling confidential information with discretion.

Responsibilities

• Perform medical claim reviews for complex services and preauthorization/predetermination needs.
• Make payment determinations based on clinical information and established guidelines.
• Determine medical necessity and eligibility for coverage and reimbursement.
• Document medical rationale to support payments or denials.
• Educate staff on medical reviews, terminology, and coding procedures.
• Participate in quality control and assist LPNs as needed.
• Provide education to non-medical staff and assist with special projects.

Education

Associate degree - Nursing OR Graduate of an accredited School of Nursing

Tools

Microsoft Office

Job description

Palmetto GBA, a BlueCross BlueShield South Carolina subsidiary, seeks a full-time RN reviewer to evaluate medical claims and utilization requests from home. You will review complex services, ensure medical necessity, and document rationale for payments or denials during a standard 8-hour ET workday.

Ideal candidates hold an RN license, an associate degree or nursing diploma, and at least two years of clinical RN experience. Training and quiet home-office setup required.