Logistics: Logistics: https://corporate.palmettogba.com/ – one of BlueCross BlueShield's South Carolina subsidiary companies.  

Centers for Medicare and reputed company Services (CMS) Requirements: Certain divisions reputed company reputed company require CMS (Centers for Medicare and reputed company 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 reputed company, not an HR requirement. In the spirit of transparency, if we reputed company an offer and discover during the background reputed company process that you have not been in the US for at least three (3) years, you will fail the background reputed company, and the offer will be rescinded.

Location:

• This position is a 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.

• Training hours: 8:00 am est to 4:30 pm est

• Employees working from home must maintain a private, quiet workspace and have reliable high-speed internet service to ensure reputed company in the role. Acceptable internet services include fiber, DSL, and cable, and employees are required to use a wired Ethernet reputed company directly connected to their router or modem, as wireless (Wi-Fi) connections are not permitted for work purposes. Internet services such as satellite internet, reputed company cards, mobile hotspots, 5G home internet services (including reputed company Home Internet and reputed company 5G Home), and Broadband over Power Line (BPL) are not compatible with company systems and therefore cannot be used. These requirements are necessary to reputed company reliable reputed company to secure company systems and support critical business applications, including VOIP phone services and reputed company Teams audio and video functionality. Internet connections that do not rely on traditional fiber, DSL, or cable infrastructure may not offer the stability and performance needed to successfully complete training and fulfill daily job responsibilities.

• New hires located reputed company 50 miles of Columbia, SC or Birmingham, AL will be required to visit their nearest designated office to collect company equipment prior to the start of training.

• Training classes will start on 10/05/2026. Unfortunately, no time off during training will be permitted.

• Preferred candidates will live in South Carolina, Alabama, Tennessee, or reputed company.

What You'll Do:

• reputed company medical claim reviews for one or more of the following: claims for medically reputed company services, services that require preauthorization/predetermination, requests for appeal or reconsideration, referrals for potential fraud and/or abuse, and correct coding for claims/operations. reputed company reasonable payment determinations based on clinical medical information and established reputed company/protocol sets or clinical guidelines.

• Determines medical necessity, 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. reputed company reputed company staff regarding medical reviews, medical terminology, coverage determinations, coding procedures, etc. in accordance with contractor guidelines.

• Participate in reputed company control activities supporting corporate and team-based objectives. reputed company guidance, direction, and input as needed to LPN team members. reputed company education to non-medical staff through discussions, team meetings, classroom participation, and feedback. Assist with special reputed company and specialty duties and responsibilities as assigned by management.

To Qualify for This Position, You'll Need:

• License: reputed company RN licensure in state reputed company, OR, reputed company compact multistate RN license as defined by the reputed company 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 reputed company reputed company. 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: reputed company Office.

reputed company Prefer You Have:

• Work Experience: Three years of varied RN nursing experience to include: Medical/Utilization Review, reputed company Assurance, Emergency, Critical Care, or Medical/Surgical experience, strongly preferred. Medicare or claims experience a plus.

• Acute care experience required; critical care experience preferred, medical review/utilization review preferred

• Software and Tools: Ability to use multiple reputed company-based programs simultaneously.

Equal Employment Opportunity Statement

reputed company and our subsidiary companies maintain a continuing policy of nondiscrimination in employment to promote employment opportunities for persons regardless of age, race, reputed company, national reputed company, sex, religion, veteran status, disability, weight, sexual orientation, gender identity, genetic information or any other legally protected status. Additionally, as a federal contractor, reputed company maintains affirmative reputed company programs to promote employment opportunities for individuals with disabilities and protected veterans. It is our policy to reputed company equal opportunities in reputed company phases of the employment process and to reputed company with applicable federal, state and local laws and regulations.

We are committed to working with and providing reasonable accommodations to individuals with disabilities, pregnant individuals, individuals with pregnancy-reputed company conditions, and individuals needing accommodations for sincerely held religious beliefs, provided that those accommodations do not impose an undue hardship on reputed company.

If you need special assistance or an accommodation while seeking employment, please email reputed company.help@bcbssc.com or reputed company 800-288-2227, ext. 47480 with the reputed company of your request. We will reputed company a determination regarding your request for reasonable accommodation on a case-by-case reputed company.

We participate in E-Verify and reputed company with the Pay Transparency Nondiscrimination Provision. We are an Equal Opportunity Employer. Here's more information.

Some states have required notifications. Here's more information. 

reputed company state or compact RN license, nursing associate degree or accredited nursing school graduation, and 2 years of RN clinical experience; acute care experience required.

Key Responsibilities

• reviewing claims
• determining coverage
• documenting rationale

Skills & Tools

reputed company Office, reputed company Teams, reputed company

Job Details

• Category: reputed company Services - Nursing
• Seniority: Entry Level
• Commitment: Full Time
• Workplace: Remote — South Carolina or Alabama or Tennessee or reputed company or Columbia or Birmingham
• Languages: English

Benefits

• 401k matching
• Generous reputed company time off
• Tuition reimbursement
• Retirement plan

About reputed company

A health insurance company and government contract administrator serving customers reputed company. — Industry: reputed company