RN Utilization Management Managed Care Coordinator

Seeking an RN with Managed Care and Utilization Management experience to review and evaluate medical or behavioral eligibility regarding benefits and clinical criteria. This position is remote, but requires the candidate to reside in the state of S.C. and attend 1 week of mandatory training onsite, then it will be fully remote. The scheduled is M-F 8:30am-5:00pm.

Essential Duties:
Review and evaluate medical or behavioral eligibility regarding benefits and clinical criteria by applying clinical expertise, administrative policies, and established clinical criteria to service requests or provides health management program interventions. Utilizes clinical proficiency, claims knowledge/analysis, and comprehensive knowledge of healthcare continuum to assess, plan, implement, coordinate, monitor, and evaluate medical necessity, options, and services required to support members in managing their health, chronic illness, or acute illness. Utilizes available resources to promote quality, cost effective outcomes.
Preferred Skills and Abilities:
Working knowledge of Microsoft Office Excel, Access, or other spreadsheet/database software. Thorough knowledge/understanding of claims/coding analysis, requirements, and processes.
Required Experience:
3 years recent clinical in defined specialty area. Specialty areas include: oncology, cardiology, neonatology, maternity, rehabilitation services, mental health/chemical dependency, orthopedic, general medicine/surgery. Or, 4 years utilization review/case management/clinical/or combination; 2 of the 4 years must be clinical.
Required Education:
Associate Degree - Nursing, OR, Graduate of Accredited School of Nursing.