(RN) Senior Medical Reviewer (Remote in SC)

July 6, 2026

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<div> Summary Acts as Team Lead for specialty programs, medical review, utilization management, and case management areas by providing assistance and support to unit supervisor/manager by giving direction/guidance/training to staff. Ensures appropriate levels of healthcare services are provided. **This position is apart of the End-Stage Renal Disease QIP Contract.*** Description Logistics: - one of BlueCross BlueShield's South Carolina subsidiary companies.<ul><li>Functions as a team leader/senior-level Medical Reviewer. Provides leadership/guidance/direction/training to staff. Maintains a working knowledge of unit functions and the ability to interpret to new hires, department interworking, and workflow. Acts as a resource for staff/external entities troubleshooting as well as resolving issues. Keeps manager informed of any problems/issues that need resolving.</li><li>Assists management with monitoring workflow and workloads (including reassignment of work to meet timelines, redirecting work intake source to balance workloads), reporting, and addressing aging issues.</li><li>Participates in departmental quality reviews. Follows a process to ensure quality plan is adhered to and communicated to all parties. Gives/receives feedback regarding medical review decision making and technical claims processing issues. Ensures that quality work instructions/forms/documents are developed/revised as needed.</li><li>Provides quality service and communicates effectively with external/internal customers in response to inquiries. Obtains information from internal departments, providers, government, and/or private agencies, etc. to resolve discrepancies/problems.</li><li>Participates in compliance initiatives and other directed activities. Participates/oversees special projects as requested by management.</li></ul>Required Education:<ul><li>Associate Degree - Nursing OR</li><li>Graduate of Accredited School of Nursing.</li></ul>Required Work Experience:<ul><li>Four years of clinical, OR</li><li>Two years of clinical and two years of medical review/utilization review, OR</li><li>Combination of health plan, clinical, and business experience totaling four years.</li></ul>Preferred requirements<ul><li>ESRD/renal dialysis experience</li><li>Five or more years9 clinical, quality management, or leadership experience as a registered nurse in a Dialysis setting.</li><li>Three or more years9 education/training/consulting experience related to Dialysis services. (may be concurrent).</li><li>Three or more years9 experience in quality management coordination related to Dialysis services. (may be concurrent)</li></ul>Required Skills and Abilities: <ul><li>Working knowledge of managed care and various forms of health are delivery systems.</li><li>Strong clinical experience to include home health, rehabilitation, and/or broad medical surgical experience.</li><li>Knowledge of specific criteria/protocol sets and the use of the same.</li><li>Working knowledge of word processing and spreadsheet software. </li><li>Ability to work independently, prioritize effectively, and make sound decisions. </li><li>Good judgment skills. </li><li>Demonstrated customer service, organizational, and presentation skills. </li><li>Demonstrated proficiency in spelling, punctuation, and grammar skills. </li><li>Demonstrated oral and written communication skills. </li><li>Ability to persuade, negotiate, or influence others. </li><li>Analytical or critical thinking skills. </li><li>Ability to handle confidential or sensitive information with discretion. </li><li>Ability to lead/direct/motivate others.</li></ul>Required Software and Tools: <ul><li>Microsoft Office.</li></ul>Required License and Certificate: <ul><li>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).</li></ul></div>

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