Medical Reviewer III

BlueCross BlueShield of South Carolina

Medical Reviewer III for BlueCross BlueShield of South Carolina performing medical reviews. Provides support in medical claims and utilization practices within the Data Strategy team.

Posted 5/15/2026full-timeRemote • Alabama, North Carolina, South Carolina • 🇺🇸 United StatesMid-LevelSeniorWebsite

About the role

Key responsibilities & impact

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, correct coding for claims/operations
Make reasonable charge payment determinations based on clinical/medical information and established criteria/protocol sets or clinical guidelines
Determine medical necessity and 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/external staff regarding medical reviews, medical terminology, coverage determinations, coding procedures, etc. in accordance with contractor guidelines
Participate in quality control activities in support of 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/responsibilities as assigned by management

Requirements

What you’ll need

Associate's in a job related field
Graduate of Accredited School of Nursing
Active, unrestricted RN licensure from the United States and in the state of hire, OR, active compact multistate unrestricted RN license as defined by the Nurse Licensure Compact (NLC), OR, current active, unrestricted licensure/certification from the United States in specialty area as required by hiring division/area
2 years clinical plus 1 year utilization/medical review, quality assurance, or home health, OR 3 years clinical
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

Benefits

Comp & perks

401(k) retirement savings plan with company match
Subsidized health plans, dental and vision coverage
Life insurance
Paid Time Off (PTO)
Nine paid holidays
On-site cafeterias and fitness centers in significant locations
Wellness programs and a healthy lifestyle premium discount
Tuition assistance
Service Recognition

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills & Tools

medical claim reviewspreauthorizationcoding proceduresmedical necessity determinationcoverage reimbursementquality control activitiesclinical guidelinesanalytical skillscritical thinking

Soft Skills

customer serviceorganizational skillsoral communicationwritten communicationgood judgmentindependent workprioritizationdecision makingeducation and training

Certifications

RN licensureNurse Licensure Compact (NLC)