Medical Reviewer II

BlueCross BlueShield of South Carolina

. 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 .

Posted 10/12/2026full-timeRemote • South Carolina • United StatesJuniorMid-LevelWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in medical claim reviews, including determination of medical necessity and appropriateness for coverage. Proficient in educating staff on medical terminology and coding procedures while ensuring compliance with established guidelines.

Highest-signal resume keywords

Active RN LicensureMedical Claim ReviewClinical ExperienceAnalytical SkillsMicrosoft Office

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Medical Necessity DeterminationCoding ProceduresPreauthorization RequestsClinical GuidelinesQuality Control ActivitiesDocumentation SkillsCharge Payment DeterminationFraud DetectionReimbursement ProcessesProcess Timeliness Monitoring

Soft Skills

Good Judgment SkillsOrganizational SkillsOral Communication SkillsWritten Communication SkillsCustomer Service Skills

Tools & Technologies

Word Processing SoftwareMicrosoft Office

Certifications & Qualifications

Active RN LicensureNurse Licensure Compact (NLC) Compliance

Industry Keywords

Medical ReviewClinical ExperienceHealthcare ComplianceConfidential Information HandlingTeam-Based Objectives

About the role

Key responsibilities & impact

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

What you’ll need

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

Comp & perks

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