RN 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 Palmetto GBA - one of BlueCross BlueShield's South Carolina subsidiary companies. Location This position is 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 8:00 AM-5:00 PM ET. It may be necessary, given the business need, to occasionally work additional hours. You must have high-speed (non-satellite) internet service and a private home office to work from home. Training classes will start on 12/7/2026. Unfortunately, no time off during training will be permitted. Preferred candidates will live in South Carolina or Alabama. What You'll Do 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. To Qualify for This Position, You'll Need: 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. What We Prefer You Have Work Experience: Five years of varied RN nursing experience to include: Medical/Utilization Review, Quality Assurance, Emergency, Critical Care, or Medical/Surgical experience, strongly preferred. Medicare or claims experience a plus. Software and Tools: Ability to use multiple Windows-based programs simultaneously. 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. 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 w #J-18808-Ljbffr ourhrconnect