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(RN) Senior Medical Reviewer (Remote in SC)

July 6, 2026

<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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Common Interview Questions And Answers

1. HOW DO YOU PLAN YOUR DAY?

This is what this question poses: When do you focus and start working seriously? What are the hours you work optimally? Are you a night owl? A morning bird? Remote teams can be made up of people working on different shifts and around the world, so you won't necessarily be stuck in the 9-5 schedule if it's not for you...

2. HOW DO YOU USE THE DIFFERENT COMMUNICATION TOOLS IN DIFFERENT SITUATIONS?

When you're working on a remote team, there's no way to chat in the hallway between meetings or catch up on the latest project during an office carpool. Therefore, virtual communication will be absolutely essential to get your work done...

3. WHAT IS "WORKING REMOTE" REALLY FOR YOU?

Many people want to work remotely because of the flexibility it allows. You can work anywhere and at any time of the day...

4. WHAT DO YOU NEED IN YOUR PHYSICAL WORKSPACE TO SUCCEED IN YOUR WORK?

With this question, companies are looking to see what equipment they may need to provide you with and to verify how aware you are of what remote working could mean for you physically and logistically...

5. HOW DO YOU PROCESS INFORMATION?

Several years ago, I was working in a team to plan a big event. My supervisor made us all work as a team before the big day. One of our activities has been to find out how each of us processes information...

6. HOW DO YOU MANAGE THE CALENDAR AND THE PROGRAM? WHICH APPLICATIONS / SYSTEM DO YOU USE?

Or you may receive even more specific questions, such as: What's on your calendar? Do you plan blocks of time to do certain types of work? Do you have an open calendar that everyone can see?...

7. HOW DO YOU ORGANIZE FILES, LINKS, AND TABS ON YOUR COMPUTER?

Just like your schedule, how you track files and other information is very important. After all, everything is digital!...

8. HOW TO PRIORITIZE WORK?

The day I watched Marie Forleo's film separating the important from the urgent, my life changed. Not all remote jobs start fast, but most of them are...

9. HOW DO YOU PREPARE FOR A MEETING AND PREPARE A MEETING? WHAT DO YOU SEE HAPPENING DURING THE MEETING?

Just as communication is essential when working remotely, so is organization. Because you won't have those opportunities in the elevator or a casual conversation in the lunchroom, you should take advantage of the little time you have in a video or phone conference...

10. HOW DO YOU USE TECHNOLOGY ON A DAILY BASIS, IN YOUR WORK AND FOR YOUR PLEASURE?

This is a great question because it shows your comfort level with technology, which is very important for a remote worker because you will be working with technology over time...