RN Medical Reviewer III

Medical Review III

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.

This is a fast-paced, highly collaborative remote role within the Data Strategy team. The ideal candidate thrives in a dynamic environment and is comfortable serving as both an independent contributor and an informal resource for peers.

The MR III functions as a subject matter expert in data strategy, providing guidance and serving as a knowledge resource for fellow nurses on the team.

This role requires ongoing, cross-functional coordination with Operations Analysts throughout the workday. Nurses identify and research providers; analysts execute the corresponding edits. The workflow is highly interdependent, with frequent email communication between teams.

Candidates must be comfortable navigating spreadsheets and interpreting reports. Understanding what the data means.

The Data Strategy nurses play a central role in generating and managing workload for the Medical Review (MRR) team. Accuracy, reliability, and attention to detail directly impact downstream operations.

This position is full-time (40 hours/week) Monday through Friday in a typical office environment. Occasional onsite attendance may be required for training and meetings at one of the following locations:

• 3700 Colonnade Pkwy, Birmingham, AL 35243
• 17 Technology Circle, Columbia, SC 29203

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 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.
• Required Work 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 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 Other Tools: Microsoft Office.

Our comprehensive benefits package includes the following:

• 401(k) retirement savings plan with company match
• Subsidized health plans, dental and vision coverage
• Life insurance
• Paid Time Off (PTO)
• Nine paid holidays
• On-site cafeterias and fitness centers in significant locations
• Wellness programs and a healthy lifestyle premium discount
• Tuition assistance
• Service Recognition

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 disabilities and 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.