RN/Managed Care Coordinator - Remote

• Title: Managed Care Coordinator/RN
• Location: Must be a local candidate within SC - Within 2 hours of Columbia
• Must have an active, unrestricted RN license in the state of South Carolina

This role involves reviewing and evaluating medical or behavioral eligibility regarding benefits and clinical criteria, primarily for Medicare Advantage. The specialist will process prior authorization requests, appeals, and conduct utilization management within a fast-paced team environment, ensuring compliance with healthcare regulations and guidelines.

• Review and evaluate medical or behavioral eligibility for benefits and clinical criteria based on established policies and clinical expertise.
• Perform medical or behavioral review/authorization processes to ensure coverage aligns with benefit and medical necessity guidelines.
• Identify and refer cases to appropriate staff such as Medical Directors, Case Managers, or Quality of Care teams.
• Participate in data collection and input for clinical information flow and claims adjudication.
• Provide discharge planning and assess service needs in collaboration with providers and facilities.
• Evaluate outcomes of care plans, benefits, and service requests, ensuring accurate documentation of clinical information.
• Communicate effectively with healthcare providers and members regarding service requests and authorizations.
• Promote enrollment in care management and health programs, and participate in on-site reviews if applicable.
• Maintain current knowledge of contracts, network status, and assist with claims discussions and resolutions.

• Active, unrestricted RN licensure, LMSW, Counselor, or Psychologist license in the U.S. and in the state of hire.
• Minimum of 4 years recent clinical experience in specialties such as oncology, cardiology, neonatology, maternity, rehabilitation, mental health, chemical dependency, orthopedic, or general medicine/surgery.
• 4 years of utilization review, case management, or clinical experience; at least 2 years must be clinical.
• Ability to process authorization requests efficiently and communicate clearly with team members.
• Strong written clinical skills for documentation and correspondence.
• Experience with Medicare or utilization review preferred.
• Soft skills include timely processing, effective communication, and teamwork.

• Bachelor's degree in Nursing or related healthcare field.
• 7+ years of healthcare program management experience.
• Licenses and certifications such as Case Manager Certification or clinical specialty certifications.
• Behavioral health or infusion therapy experience.

Candidates with relevant clinical and utilization management experience are encouraged to apply. Join a dynamic team dedicated to delivering quality healthcare services in a fast-paced environment.

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