Medical Reviewer II

BlueCross BlueShield of South Carolina

Medical Reviewer II performing clinical reviews and documentation for medical claims at Palmetto GBA. Requires clinical experience and strong skills in medical terminology and coding protocols.

Posted 4/23/2026full-timeRemote • South Carolina • 🇺🇸 United StatesJuniorMid-LevelWebsite

About the role

Key responsibilities & impact

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
Makes reasonable charge payment determinations based on clinical/medical information and established criteria/protocol sets or clinical guidelines
Determines medical necessity and appropriateness and/or reasonableness and necessity for coverage and reimbursement
Monitors process’s timeliness in accordance with contractor standards
Educates internal/external staff regarding medical reviews, medical terminology, coverage determinations, coding procedures, etc. in accordance with contractor guidelines
Participates in quality control activities in support of the corporate and team-based objectives
Provides guidance, direction, and input as needed to LPN team members
Provides education to non-medical staff through discussions, team meetings, classroom participation, and feedback
Assists with special projects and specialty duties/responsibilities as assigned by management

Requirements

What you’ll need

Associate's in a job-related field
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
Active RN licensure in state hired, OR, active compact multistate RN license as defined by the Nurse Licensure Compact (NLC)

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

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills & Tools

medical reviewsclinical guidelinesmedical claims reviewcharge payment determinationsmedical necessity determinationcoding proceduresquality control activitiesclinical experienceanalytical skillscritical thinking

Soft Skills

independent workprioritizationdecision makinggood judgmentcustomer serviceorganizational skillsoral communicationwritten communicationdiscretionteam guidance

Certifications

Associate's degreeactive RN licensurecompact multistate RN license