RN Medical Reviewer II - Palmetto GBA

Summary 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. Description Logistics: Palmetto GBA– one of BlueCross BlueShield’s South Carolina subsidiary companies. 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 12/7/2026. Unfortunately, no time off during training will be permitted. Preferred candidates will live in South Carolina or Alabama. What You'll Do: 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, and correct coding for claims/operations. Make reasonable payment determinations based on clinical medical information and established criteria/protocol sets or clinical guidelines. Determines medical necessity, appropriateness, and/or reasonableness and necessity for co