RN Medical Reviewer II

BlueCross BlueShield of South Carolina

. Perform medical reviews using clinical and medical information from physicians/providers and established criteria, protocol sets, or clinical guidelines .

Posted 10/16/2026full-timeUnited StatesJuniorMid-LevelWebsite

Core Competencies

Role fit

Core Competencies

Use this summary to align your resume positioning with the role.

Demonstrates expertise in performing medical reviews and documenting decisions based on clinical guidelines and protocols. Proficient in analyzing clinical information and managing appeals while ensuring compliance with regulations and standards.

Highest-signal resume keywords

Active RN LicensureClinical ExperienceMedical Review ExpertiseAnalytical SkillsMicrosoft Office Proficiency

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Medical ReviewClinical DocumentationUtilization ReviewAppeals ManagementQuality-of-Care AssessmentProtocol AdherenceClinical Guidelines ApplicationDecision DocumentationRegulatory ComplianceCritical Thinking

Soft Skills

Good JudgmentCustomer ServiceOrganizational SkillsOral CommunicationWritten Communication

Tools & Technologies

Word Processing SoftwareMicrosoft Office

Certifications & Qualifications

Associate's DegreeNursing License

Industry Keywords

Clinical GuidelinesMedical ClaimsUtilization PracticesConfidential InformationNurse Licensure Compact

About the role

Key responsibilities & impact

Perform medical reviews using clinical and medical information from physicians/providers and established criteria, protocol sets, or clinical guidelines
Document decisions using applicable protocol sets or clinical guidelines
Provide support and review of medical claims and utilization practices
Document the basis of appeals or retrospective reviews accurately, timely, and in accordance with regulations or standards
Research member and provider service appeals using clinical documentation, contractual requirements, governing agency requirements, policies, and procedures
Perform appeal and retrospective reviews to determine precedence of pertinent issues in applying policies, procedures, clinical information, and benefit or policy provisions
Perform special projects, including reviews of clinical information to identify quality-of-care issues
Work a 40-hour week on an 8-hour Monday-Friday shift within 8:00 a.m.-4:30 p.m.

Requirements

What you’ll need

Associate's degree in a job-related field, or graduate of an accredited school of nursing
2 years of clinical experience
Active RN licensure in the state hired, or active compact multistate RN license as defined by the Nurse Licensure Compact (NLC)
Working knowledge of word processing software
Microsoft Office proficiency
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
No sponsorship eligibility now or in the future

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
Benefits eligibility beginning the first of the month following 28 days of employment