Medical Reviewer II

About the role

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. Logistics: Palmetto GBA - one of BlueCross BlueShield's South Carolina subsidiary companies. Centers for Medicare and Medicaid Services (CMS) Requirements: Certain divisions within BlueCross BlueShield of South Carolina require CMS (Centers for Medicare and Medicaid Services) residency that requires employees to have lived in the US for at least three (3) out of the last five (5) years. This is a business requirement - government contracts, not an HR requirement. In the spirit of transparency, if we extend an offer and discover during the background check process that you have not been in the US for at least three (3) years, you will fail background, and the offer will be rescinded. 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 8/17/2026. Unfortunately, no time off during training will be permitted. Preferred candidates will live in South Carolina or Alabama.

Responsibilities

• 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.
• 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 We Can Do for You:
• We understand the value of a diverse and inclusive workplace and strive to be an employer where employees across all spectrums have the opportunity to develop their skills, advance their careers and contribute their unique abilities to the growth of our company.
• What To Expect Next:
• After submitting your application, our recruiting team me

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