Registered Nurse Case Manager – Hospice
Mission Healthcare
RN Medical Reviewer II
BlueCross BlueShield of South Carolina
full-time
Posted on:
Origin: • 🇺🇸 United States • Alabama, South Carolina
Visit company websiteJob Level
JuniorMid-Level
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.
- Location: Palmetto GBA – one of BlueCross BlueShield’s South Carolina subsidiary companies.
- Location and training: 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 start on 06/23/25 and 07/21/25. No time off during training.
- What You'll Do: Perform medical claim reviews for medically complex services and preauthorization/predetermination; determine medical necessity and payment determinations; monitor timeliness; document medical rationale; educate staff; participate in quality control; mentoring; assist with special projects and specialty duties and responsibilities as assigned by management.
Requirements
- 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.
