RN Medical Reviewer II

Why should you join the BlueCross BlueShield of South Carolina family of companies? Other companies come and go, but we’ve been part of the national landscape for more than seven decades, 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, allowing us to build on various business strengths. We deliver outstanding service to our customers. If you are dedicated to the same philosophy, consider joining our team!

In this role, you will review home health and hospice documentation submitted by providers to make sure it meets all program requirements, such as the face-to-face encounter, plan of care, and supporting clinical documentation. This is a great opportunity for nurses who thrive in high-intensity clinical settings and are ready to put that expertise to work in a supportive, work-from-home environment.

Position Purpose:
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 of South Carolina’s subsidiary companies.

Location: This position is full-time (40 hours/week), Monday–Friday, and is Work at Home (W@H). To work from home, you must have high-speed (non-satellite) internet service and a private home office.

Training lasts approximately 4 weeks, 8:00 AM–4:30 PM Eastern Time. After training, associates may set their core hours within our business hours of 6:00 AM–7:00 PM Eastern Time.

Sponsorship: This position is not eligible for sponsorship now or in the future.

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:

• Associate Degree – Nursing, OR
• Graduate of an accredited School of Nursing

Required Work Experience:

• Two years clinical experience.

Required Skills and Abilities:

• Working knowledge of word processing software.
• Ability to work independently, prioritize effectively, and make sound decisions.
• 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 Tools:

• Microsoft Office

Required Licenses and Certificates:

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

We Prefer That You Have The Following:

• Critical care experience in a high-intensity setting such as ER or ICU
• Home health and/or hospice experience
• Familiarity with home health and hospice documentation requirements, such as face-to-face encounters and plans of care

Our Comprehensive Benefits Package Includes The Following:
We offer our employees great benefits and rewards. You will be eligible to participate in our benefits program 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 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. While your application is active, please monitor your email, including your spam folder, so you don’t miss any important updates from our recruiting team.

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.

If you need special assistance or an accommodation while seeking employment, please email mycareer.help@bcbssc.com or 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.

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

Some states have required notifications. Here's more information.

Talent Community

If you don’t have an account with us and don’t see the dream job you are looking for, click on the link above to Join Our Talent Community by submitting your resume and contact information and we will reach out if we find a good fit.

About Us

Palmetto GBA is a healthcare service administrator and one of the nation’s largest providers of high-volume medical claims and transaction processing.

We provide services and technology solutions to improve and streamline healthcare administration not only for government but also for corporate entities.

We offer a wide range of services that require a diverse workforce and expansive areas of expertise from data analytics, administrative and workflow services to advanced systems.

To help our associates succeed and reach their professional goal, we offer training classes and programs that help employees prepare for leadership positions and offer tuition assistance for education advancement. Palmetto GBA acknowledges associates’ hard work and dedication with awards and financial incentives.

Veterans Welcome!

Palmetto GBA is a strong supporter of our veterans, and many service men and women have joined our ranks. We’ve found the dedication, work ethic and job skills that serve well in the military excel in many of our lines of business, and we proudly have veterans filling positions in Human Resources, Information Technology, Customer Service, Operations, General Services and more.

If you are a full-time employee in the National Guard or Reserves, we will even cover the difference in your pay if you are called to active duty.

Join Us

If you're ready to join in a diverse company with secure, community roots and an innovative future, apply for a position now!