We are currently hiring for a Medical Reviewer II to join BlueCross BlueShield of South Carolina. In this role as Medical Reviewer II, 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’ve 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 dedicated 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.

• 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.

• Associates in a job-related field.
• Graduate of Accredited School of Nursing.

• Two 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).

• 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 healthy lifestyle premium discount.
• Tuition assistance.
• Service recognition.
• Incentive Plan.
• Merit Plan.
• Continuing education funds for additional certifications and certification renewal.