Medical Reviewer II - Palmetto GBA

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.

Logistics:  - one of Blue Cross Blue Shield's South Carolina subsidiary companies.

Centers for Medicare and Medicaid Services (CMS) Requirements:
Certain divisions within Blue Cross Blue Shield of South Carolina require CMS (Centers for Medicare and Medicaid Services) residency that requires employees to have lived in the US for at least three (3) out of the last five (5) years. This is a business requirement - government contracts, not an HR requirement. In the spirit of transparency, if we extend an offer and discover during the background check process that you have not been in the US for at least three (3) years, you will fail the background check, and the offer will be rescinded.

Location:

This position is a full-time salaried position Monday-Friday in a typical home office environment. You will work an 8-hour shift scheduled during our normal business hours of 8:00AM-5:00PM ET. It may be necessary, given the business need, to occasionally work additional hours.

Training hours: 8:00 am est to 4:30 pm est Employees working from home must maintain a private, quiet workspace and have reliable high-speed internet service to ensure success in the role. Acceptable internet services include fiber, DSL, and cable, and employees are required to use a wired Ethernet connection directly connected to their router or modem, as wireless (Wi-Fi) connections are not permitted for work purposes.

Internet services such as satellite internet, air cards, mobile hotspots, 5G home internet services (including T-Mobile Home Internet and Verizon 5G Home), and Broadband over Power Line (BPL) are not compatible with company systems and therefore cannot be used. These requirements are necessary to provide reliable access to secure company systems and support critical business applications, including VOIP phone services and Microsoft Teams audio and video functionality.

Internet connections that do not rely on traditional fiber, DSL, or cable infrastructure may not offer the stability and performance needed to successfully complete training and fulfill daily job responsibilities.

New hires located within 50 miles of Columbia, SC or Birmingham, AL will be required to visit their nearest designated office to collect company equipment prior to the start of training. Training classes will start on 10/05/2026. Unfortunately, no time off during training will be permitted. Preferred candidates will live in South Carolina, Alabama, Tennessee, or Georgia.

Perform 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, and correct coding for claims/operations. Make reasonable payment determinations based on clinical medical information and established criteria/protocol sets or clinical guidelines. Determines medical necessity, appropriateness, and/or reasonableness and necessity for coverage and reimbursement.

Monitor process's timeliness in accordance with contractor standards. Document medical rationale to justify payment or denial of services and/or supplies. Educate internal and external staff regarding medical reviews, medical terminology, coverage determinations, coding procedures, etc. in accordance with contractor guidelines. Participate in quality control activities supporting corporate and team-based objectives. Provide guidance, direction, and input as needed to LPN team members.

Provide education to non-medical staff through discussions, team meetings, classroom participation, and feedback. Assist with special projects and specialty duties and responsibilities as assigned by management.

License:
Active RN licensure in state hired, OR, active compact multistate RN license as defined by the Nurse Licensure Compact (NLC).

Education:

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

Work Experience:

Two years of clinical experience as an RN.

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.

Software and Tools:
Microsoft Office.

Work Experience:

Three years of varied RN nursing experience to include:
Medical/Utilization Review, Quality Assurance, Emergency, Critical Care,…