Summary
 

Palmetto GBA is looking for Registered Nurses to join our RCD (Review Choice Demonstration) Medicare Medical Review team.

Position Purpose:
Selected candidates will be reviewing medical records to determine medical necessity and eligibility under RCD guidelines. In this position, you will ensure that the member is receiving the best care for their condition based on standard protocols and guidelines. Position will be computer based with no regular patient/provider contact.

This work from home role will need strong clinical, time management and computer skills. Excellent for those individuals looking to transition their career from direct patient care to working from home. No regular nights, weekends, or holidays to allow you a good work/home life balance.

Description
 

Logistics:

Palmetto GBA https://corporate.palmettogba.com/ – one of BlueCross BlueShield’s South Carolina subsidiary companies.

Location:

• This position is full-time (40-hours/week) 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. It may be necessary, given the business need to work occasional overtime
• Work from home after one week of onsite training in Columbia, SC, or Birmingham, AL. You must have high-speed (non-satellite) internet service and a private home office to work from home.
• Six weeks of training class with one week of onsite training and five weeks of remote training.  Training class will start on 05/27/25.  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 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. Educate internal and external staff regarding medical reviews, medical terminology, coverage determinations, coding procedures, etc. in accordance with contractor guidelines.
• Participate in quality control activities supporting corporate and team-based objectives. Provide guidance, direction, and input as needed to LPN team members. Provide education to non-medical staff through discussions, team meetings, classroom participation, and feedback. Assist with special projects and specialty duties and responsibilities as assigned by management.

To Qualify for This Position, You'll Need:

• License: Active RN licensure in state hired, OR, active compact multistate RN license as defined by the Nurse 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 make