(RN) Medical Reviewer II - Palmetto GBA (2024)

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

Why should you join the BlueCross BlueShield of South Carolina family of companies? Other companies come and go, but for more than seven decades we have been part of the national landscape, with our roots firmly embedded in the South Carolina community. We are the largest insurance company in South Carolina … and much more. We are one of the nation’s leading administrators of government contracts. We operate one of the most sophisticated data processing centers in the Southeast. We also have a diverse family of subsidiary companies that allows us to build on a variety of business strengths. We deliver outstanding service to our customers. If you are committed to the same philosophy, consider joining our team!

Here is your opportunity to join a dynamic team at a diverse company with secure, community roots and an innovative future.



  • Work hours during training 8:00 am to 5:00 pm Monday through Friday.
  • Work from home following onsite training. To work from home, you must have high-speed (non-satellite) internet service and a private home office.

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 reimbursem*nt. 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:

  • Associate Degree - Nursing, OR ​Graduate of Accredited School of Nursing
  • An active, unrestricted RN license 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)
  • Two years clinical experience as an RN.
  • Microsoft Office.

We Prefer That You Have:

  • Two years Medical/Utilization Review or Public Health experience strongly preferred.
  • Bachelor's degree - Nursing (BSN)
  • Medicare Part B experience.
  • Medical/Surgical or Emergency Room experience.

What We Can Do for You

Our comprehensive benefits package includes:

  • 401(k) retirement savings plan with company match
  • Subsidized health plans and free vision coverage
  • Life insurance
  • Paid annual leave — the longer you work here, the more you earn
  • Nine paid holidays
  • On-site cafeterias and fitness centers in major locations
  • Wellness programs and a healthy lifestyle premium discount
  • Tuition assistance
  • Service recognition

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. Management will be conducting interviews with the most qualified candidates.

We participate in E-Verify and comply with the Pay Transparency Nondiscrimination Provision. We are an Equal Opportunity Employer.

Some states have required notifications. Here'smore information.

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 minorities, females, disabled individuals and 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 physical and mental disabilities.

If you need special assistance or an accommodation while seeking employment, please e-mail mycareer.help@bcbssc.com or call 1-800-288-2227, 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.

(RN) Medical Reviewer II - Palmetto GBA (2024)


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