Medical Reviewer II

🔥 13 hours ago

🌴 South Carolina – Remote

🌴 South Carolina – Remote

⏰ Full Time

🟢 Junior

🟡 Mid-level

🔍🏥 Medical Reviewer

👻 Ghost score 10%

What it means: how likely this posting is sitting open without active hiring.How to read it: 60% or higher means we think this is a ghost. Lower scores are less of a worry.How we score it: age, reposts, open roles vs team size, how fast jobs close, and whether pay is listed.Fine print: an estimate from public data, not a judgment of the company. Real jobs can score high, so treat it as a hint, not a fact.

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BlueCross BlueShield of South Carolina

WebsiteLinkedInAll Job Openings

10,000+ employees

Founded 1946

🏥 Healthcare

💼 Consulting

⚖️ Legal

Healthcare • Consulting • Legal

BlueCross BlueShield of South Carolina is a leading health insurance provider that offers a variety of health plans, including individual and family plans, Medicare options, and group health plans. The organization focuses on providing coverage and resources for members, employers, and healthcare providers, ensuring access to quality healthcare services. With a commitment to promoting healthier lifestyles and supporting community health, BlueCross BlueShield of South Carolina plays a vital role in the healthcare landscape of the region.

📋 Description

• Performs medical claim reviews for medically complex services, preauthorization/predetermination requests, appeals or reconsiderations, potential fraud and/or abuse referrals, and correct coding for claims/operations • Makes reasonable charge payment determinations using clinical/medical information and established criteria, protocol sets, or clinical guidelines • Determines medical necessity, appropriateness, and reasonableness for coverage and reimbursement • Monitors process timeliness in accordance with contractor standards • Documents medical rationale supporting payment or denial of services and/or supplies • Educates internal and external staff regarding medical reviews, medical terminology, coverage determinations, and coding procedures • Participates in quality control activities supporting corporate and team-based objectives • Provides guidance, direction, and input to LPN team members • Educates non-medical staff through discussions, team meetings, classroom participation, and feedback • Assists with special projects and specialty duties assigned by management

🎯 Requirements

• Associate's in a job-related field • Graduate of Accredited School of Nursing • 2 years clinical experience • 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 • Microsoft Office • Active RN licensure in state hired, OR, active compact multistate RN license as defined by the Nurse Licensure Compact (NLC) • U.S. Citizenship required to obtain the required security clearance • Ability to work an 8-hour shift during normal business hours, Monday-Friday, with occasional overtime as needed

🏖️ Benefits

• 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