RN Medical Reviewer II

BlueCross BlueShield of South Carolina

. Review home health and hospice documentation submitted by providers for program requirements, including face-to-face encounters, plans of care, and supporting clinical documentation .

Posted 11/2/2026full-timeRemote • South Carolina • United StatesJuniorMid-LevelWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in medical claim reviews, documentation requirements, and clinical guidelines while providing education and guidance to both medical and non-medical staff. Proficient in analyzing clinical information to determine medical necessity and appropriateness for home health and hospice services.

Highest-signal resume keywords

Active RN LicensureMedical Claim ReviewClinical Documentation AnalysisCritical Thinking SkillsCustomer Service Skills

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Clinical ExperienceMedical Necessity DeterminationCoding AccuracyQuality Control ActivitiesDocumentation of Medical Rationale

Soft Skills

Organizational SkillsOral Communication SkillsWritten Communication SkillsAbility to Work IndependentlyPrioritization Skills

Tools & Technologies

Microsoft OfficeWord Processing SoftwareHigh-Speed Internet Service

Certifications & Qualifications

Associate Degree – NursingActive Compact Multistate RN License

Industry Keywords

Home HealthHospiceFace-to-Face EncountersPlans of CareCritical Care Experience

About the role

Key responsibilities & impact

Review home health and hospice documentation submitted by providers for program requirements, including face-to-face encounters, plans of care, and supporting clinical documentation
Perform medical claim reviews for medically complex services, preauthorization/predetermination requests, appeals or reconsiderations, potential fraud and/or abuse referrals, and coding accuracy
Make charge payment determinations using clinical information and established criteria, protocols, or clinical guidelines
Determine medical necessity, appropriateness, reasonableness, and coverage/reimbursement necessity
Monitor review timeliness according to contractor standards
Document medical rationale supporting payment or denial of services and supplies
Educate internal and external staff on medical reviews, terminology, coverage determinations, and coding procedures
Participate in quality control activities supporting corporate and team objectives
Provide guidance, direction, and input to LPN team members
Educate non-medical staff through discussions, team meetings, classroom participation, and feedback
Assist with special projects and specialty duties assigned by management

Requirements

What you’ll need

Associate Degree – Nursing, OR graduate of an accredited School of Nursing
Two years clinical experience
Active RN licensure in state hired, OR active compact multistate RN license as defined by the Nurse Licensure Compact (NLC)
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
Microsoft Office
High-speed non-satellite internet service
Private home office
Position is not eligible for sponsorship now or in the future
Preferred: Critical care experience in a high-intensity setting such as ER or ICU
Preferred: Home health and/or hospice experience
Preferred: Familiarity with home health and hospice documentation requirements, such as face-to-face encounters and plans of care

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
Opportunity to develop skills, advance careers, and contribute to company growth