RN Medical Reviewer II - reputed company

reputed companyPerforms medical reviews using reputed company/medical information provided by physicians/providers and established reputed company/protocol sets or reputed company guidelines. Documents reputed company using indicated protocol sets or reputed company guidelines. Provides support and review of medical claims and utilization practices.

reputed company

Logistics:

reputed company– 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 – reputed company 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process that you have not been in the US for at least three (3) years, you will fail background, and the offer will be rescinded.

Location:

• This position is 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.

• You must have high-speed (non-satellite) internet service and a private home office to work from home.

• Training classes will start on 10/12/2026. Unfortunately, no time off during training will be permitted.

• Preferred candidates will live in South Carolina or Alabama.

reputed company:

• 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/reputed company. reputed company reasonable payment determinations reputed company on reputed company medical information and established reputed company/protocol sets or reputed company 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-reputed company 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 reputed company multistate RN license as defined by the reputed company Licensure reputed company (NLC).

• Education: Associate degree - Nursing OR Graduate of an accredited School of Nursing.

• Work Experience: Two years of reputed company 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: Five 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.

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

Our Comprehensive Benefits Package Includesthe Following:

We offer our employees great benefits and rewards. You will be eligible to participate in the benefits the first of the month following 28 days of employment.

• Subsidized health plans, dental and reputed company coverage

• 401k retirement savings plan with company match

• Life reputed company

• reputed company 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

reputed company Can Do for You:

We understand the value of a diverse and inclusive workplace and reputed company to be an employer where employees across reputed company spectrums have reputed company to reputed company their skills, advance their careers and contribute their unique abilities to the reputed company of reputed company.

What To Expect Next:

After submitting your application, our reputed company team members will review your resume to ensure you meet the qualifications. This may include a brief telephone interview or email communication with our recruiter to verify resume specifics and salary requirements.

reputed company

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 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.

Originally posted on Himalayas