RN Medical Reviewer III (W@H South Carolina)

BlueCross BlueShield of South Carolina; Charleston (SC); Remote; USD 70,000 - 90,000; Full time

Job summary

A leading healthcare organization seeks an RN Medical Reviewer III to conduct medical reviews and support the management of medical claims. This fully remote role requires an active RN license and involves critical review for medical necessity while ensuring adherence to established criteria. The position offers a chance to engage in quality control and educate staff, promoting a healthy work environment where diverse practices are celebrated.

Benefits

Subsidized health plans

401k retirement savings plan

Paid Time Off (PTO)

Education Assistance

Life Insurance

Qualifications

• Active RN licensure required, with experience in clinical and utilization review.
• Knowledge of managed care and healthcare delivery systems considered essential.
• Ability to work independently and make sound decisions under pressure.

Responsibilities

• Perform medical claim reviews for complex services and determine medical necessity.
• Educate staff on medical reviews and coding procedures.
• Participate in quality control activities and provide guidance to team members.

Skills

Clinical experience

Medical terminology knowledge

Analytical thinking

Communication skills

Education

Associates in a job-related field

Bachelor's Degree - Nursing (preferred)

Tools

Microsoft Office

Job description

RN Medical Reviewer III (W@H South Carolina)

United States, South Carolina, Charleston

May 29, 2025

Summary We are currently hiring for a Medical Reviewer III to join BlueCross BlueShield of South Carolina. In this role as a Medical Reviewer III, you will perform medical reviews using clinical/medical information provided by physicians/providers and established criteria/protocol sets or clinical guidelines, document decisions using indicated protocol sets or clinical guidelines, and provide support and review of medical claims and utilization practices. Description

Location:

This position is full-time (40 hours/week) Monday-Friday with an 8-hour shift from 6:00am-5:00pm EST and will be fully remote. Candidates may be asked to report on-site occasionally for trainings, meetings, or other business needs.

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: Associates in a job-related field
• Degree Equivalency: Graduate of Accredited School of Nursing
• Required Experience: 2 years clinical plus 1 year utilization/medical review, quality assurance, or home health, OR 3 years clinical. FOR PALMETTO GBA (CO. 033) ONLY: 2 years clinical experience plus 2 years utilization/medical review, quality assurance, or home health experience.
• Required Skills and Abilities: Working knowledge of managed care and various forms of health care delivery systems; strong clinical experience to include home health, rehabilitation, and/or broad medical surgical experience. Knowledge of specific criteria/protocol sets and the use of the same.
• 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.
• Ability to persuade, negotiate, or influence others.
• 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, unrestricted RN licensure from the United States and in the state of hire, OR, active compact multistate unrestricted RN license as defined by the Nurse Licensure Compact (NLC), OR, current active, unrestricted licensure/certification from the United States and in the state of hire in specialty area as required by hiring division/area.

What We Prefer You to Have:

• Preferred Education: Bachelor's Degree-Nursing or Graduate of accredited School of Nursing.
• Preferred Work Experience: Must have well rounded clinical experience.
• Preferred Work Experience: 3 years' utilization/medical review, quality assurance, or home health, plus 5 years clinical experience.
• Preferred Skills and Abilities: Knowledge of spreadsheet and database software. Knowledge of Medicare and/or regulations/policies/instructions/provisions, home health, and/or system/processing procedures for medical review.
• Preferred Software and Other Tools: Working knowledge of Microsoft Excel, Access, or other spreadsheet database software.

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 understand the value of a diverse and inclusive workplace and 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.

What To Expect Next:

After submitting your application, our recruiting team members will review your resume to ensure you meet the qualifications. This may include a brief telephone interview or email communication with our recruiter to verify resume specifics and salary requirements.

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 disabilitiesand 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.

If you need special assistance or an accommodation while seeking employment, please email [e-mail] call 800-288-2227, ext. 47480 with the nature of your request. We will make a determination regarding your request for reasonable accommodation on a case-by-case basis.

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