Medical Reviewer III – Home Health and Hospice

CGS Administrators, LLC

Medical Reviewer III handling complex medical claim reviews and ensuring compliance with clinical guidelines for BlueCross BlueShield of South Carolina. Join a longstanding insurance leader providing quality service in the healthcare sector.

Posted 7/10/2026full-timeRemote • Tennessee, Texas, Utah, Vermont • 🇺🇸 United StatesMid-LevelSenior💰 $51,107 - $97,729 per yearWebsite

About the role

Key responsibilities & impact

Performs medical claim reviews for 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
Makes reasonable charge payment determinations based on clinical/medical information and established criteria/protocol sets
Determines medical necessity and appropriateness and/or reasonableness and necessity for coverage and reimbursement
Documents medical rationale to justify payment or denial of services and/or supplies
Educates internal/external staff regarding medical reviews, medical terminology, coverage determinations, coding procedures, etc.
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

Required Education: Associate's in a job related field
Degree Equivalency: Graduate of Accredited School of Nursing
Required Experience: 2 years clinical plus 1 year utilization/medical review, quality assurance, or home health, OR 3 years clinical.
Working knowledge of managed care and various forms of health care delivery systems
Strong clinical experience to include home health, rehabilitation, and/or broad medical surgical experience.
Knowledge of specific criteria/protocol sets and the use of the same.
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.
Ability to persuade, negotiate, or influence others.
Analytical or critical thinking skills.
Ability to handle confidential or sensitive information with discretion.
Required Software and Tools: Microsoft Office.
Required Licenses and Certificates: 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 and in the state of hire in specialty area as required by hiring division/area.

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

✓ Tailor your resume

Applicant Tracking System Keywords

Tip: use these terms in your resume and cover letter to boost ATS matches.

Hard Skills & Tools

Correct CodingMedical Necessity DeterminationClinical DocumentationQuality Control ActivitiesManaged Care KnowledgeHealthcare Delivery SystemsAnalytical SkillsCritical Thinking

Soft Skills

Good JudgmentCustomer Service SkillsOrganizational SkillsOral CommunicationWritten CommunicationPersuasion Skills

Certifications

Active RN LicensureNurse Licensure Compact (NLC) Certification