Summary
Performs medical reviews using clinical/medical information provided by physicians/providers and established criteria/protocol sets or clinical guidelines. Documents decisions using indicated protocol sets or clinical guidelines. Provides support and review of medical claims and utilization practices.
Description
Logistics
Palmetto GBA– one of BlueCross BlueShield’s South Carolina subsidiary companies.
Location
- This position is full-time salaried position Monday-Friday in a typical home office environment. You will work an 8-hour shift scheduled during our normal business hours of 8:00AM-5:00PM ET. It may be necessary, given the business need, to occasionally work additional hours.
- You must have high-speed (non-satellite) internet service and a private home office to work from home.
- Six-week paid training class with one week of onsite training and five weeks of remote training. One week of onsite training in Columbia, SC, or Birmingham, AL.
- Training classes will start on 11/16/2026. Unfortunately, no time off during training will be permitted.
- Preferred candidates will live in South Carolina or Alabama.
What You'll Do
- Perform 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, and correct coding for claims/operations. Make reasonable payment determinations based on clinical medical information and established criteria/protocol sets or clinical guidelines.
- Determines medical necessity, appropriateness, and/or reasonableness and necessity for coverage and reimbursement. Monitor process’s timeliness in accordance with contractor standards. Document medical rationale to justify payment or denial of services and/or supplies. Educate internal and external staff regarding medical reviews, medical terminology, coverage determinations, coding procedures, etc. in accordance with contractor guidelines.
- Participate in quality control activities supporting corporate and team-based objectives. Provide guidance, direction, and input as needed to LPN team members. Provide education to non-medical staff through discussions, team meetings, classroom participation, and feedback. Assist with special projects and specialty duties and responsibilities as assigned by management.
To Qualify for This Position, You'll Need
- License: Active RN licensure in state hired, OR, active compact multistate RN license as defined by the Nurse Licensure Compact (NLC).
- Education: Associate degree - Nursing OR Graduate of an accredited School of Nursing.
- Work Experience: Two years of clinical experience as an RN.
- Skills and Abilities: 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.
- Software and Tools: Microsoft Office.
What We Prefer You Have
- Work Experience: Five years of varied RN nursing experience to include: Medical/Utilization Review, Quality Assurance, Emergency, Critical Care, or Medical/Surgical experience, strongly preferred. Medicare or claims experience a plus.
- Software and Tools: Ability to use multiple Windows-based programs simultaneously.
Our Comprehensive Benefits Package Includes the Following
We offer our employees great benefits and rewards. You will be eligible to participate in the benefits the first of the month following 28 days of employment.
- 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
What To Expect Next
After submitting your application, our recruiting team members will review your resume to ensure you meet the qualifications. This may include a brief telephone interview or email communication with our recruiter to verify resume specifics and salary requirements.
Palmetto GBA
We are committed to working with and providing reasonable accommodations to individuals with disabilities, pregnant individuals, individuals with pregnancy-related conditions, and individuals needing accommodations for sincerely held religious beliefs, provided that those accommodations do not impose an undue hardship on the Company.
If you need special assistance or an accommodation while seeking employment, please email mycareer.help@bcbssc.com or call 800-288-2227, ext. 47480 with the nature of your request. We will make a determination regarding your request for reasonable accommodation on a case-by-case basis.
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