South Carolina Board Of Nursing – RN Medical Reviewer II

South Carolina Board of Nursing: Protecting Public Health Through Professional Standards

The South Carolina Board of Nursing plays a vital role in safeguarding public health by ensuring that nurses across the state practice safely and competently. Operating under the South Carolina Department of Labor, Licensing, and Regulation (LLR), the board oversees licensing, professional standards, and regulatory compliance for nurses. Its primary mission focuses on protecting the public by verifying that both new and experienced nurses meet the education, training, and ethical standards required for responsible healthcare practice.

Located in Columbia, South Carolina, the board manages licensing procedures, professional oversight, and communication with nursing professionals across the state. Through its regulatory responsibilities, the organization evaluates applications, issues nursing licenses, and ensures that nurses maintain the skills and knowledge necessary to deliver quality care. By monitoring professional conduct and continuing competency, the board helps maintain trust in the nursing profession.

South Carolina is also a participant in the Nurse Licensure Compact (NLC), which offers additional flexibility for nurses practicing across state lines. Nurses who already hold a multistate compact license can practice in South Carolina without obtaining a separate license, making it easier for healthcare professionals to work in multiple states and respond to workforce needs. For those applying directly in South Carolina, licensing fees vary depending on the application type, including licensure by examination or endorsement.

Through licensing oversight, regulatory enforcement, and collaboration with healthcare organizations, the South Carolina Board of Nursing helps maintain high standards throughout the state’s healthcare system. By ensuring that qualified professionals provide patient care, the board continues to support safe nursing practice while strengthening the overall quality of healthcare for communities across South Carolina.

Is South Carolina a compact nursing state?

South Carolina is a Nursing Licensure Compact state. In South Carolina, Certified Nurse Practitioners, Clinical Nurse Specialists, and Certified Nurse-Midwives may apply for prescriptive authority for controlled substances and schedules III to V in collaboration with physicians.

What are the best nursing schools in SC?

The Best Nursing Schools in South Carolina (SC) in 2018. 1. Charleston Southern University, Charleston, SC. Charleston Southern University is a private university that offers a fantastic Bachelor of Science in Nursing degree.

What is the SC State Board of Nursing?

South Carolina Board of Nursing is the administrative board and council that regulates and enforces public safety and welfare by promoting efficient and legal nurse practicing in the state. Board is an integral member of NCSBN and follows various guidelines specified in the Nurse Practice Act.

What is a nurse compact state?

A nursing compact state is a state that has joined the Nurse Licensure Compact (NLC) after passing legislation that accepts the Compact and incorporating the provisions into the state’s Nurse Practice Act. The NLC is an agreement among member states to honor nurse licensure of other member states for registered and practical/vocational nurses.

RN Medical Reviewer II – Palmetto GBA – BlueCross BlueShield of South Carolina

Summary

Possibility to work remotely once fully trained for residents in South Carolina.
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.

Job Description

• 70% Performs 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, correct coding for claims/operations. Makes reasonable charge payment determinations based on clinical/medical information and established criteria/protocol sets or clinical guidelines. Determines medical necessity and appropriateness and/or reasonableness and necessity for coverage and reimbursement. Monitors the process’s timeliness following contractor standards. Documents medical rationale to justify payment or denial of services and/or supplies.
• 20% Educates internal/external staff regarding medical reviews, medical terminology, coverage determinations, coding procedures, etc. by contractor guidelines.
  10% Participates in quality control activities in support of the corporate and team-based objectives. Provides guidance, direction, and input as needed to LPN team members. Provides education to non-medical staff through discussions, team meetings, classroom participation, and feedback. Assists with special projects and specialty duties/responsibilities as assigned by management.

Required Skills and Abilities :

• Working knowledge of word processing software.
• Ability to work independently, prioritize effectively, and make sound decisions.
• 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.

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