Job Description

Job Description

Job Description

Must live within 2 hours of Columbia
Must be willing to work onsite the first 2-3 weeks for training, then fully remote
Must have an active RN License in the State of South Carolina
Overview

This role involves reviewing and evaluating medical or behavioral eligibility regarding benefits and clinical criteria to ensure coverage aligns with guidelines. The candidate will perform authorization processes, discharge planning, and communicate with providers and members within a fast-paced, team-oriented environment.

• Review and evaluate medical or behavioral benefit eligibility based on clinical expertise and established policies.
• Perform medical or behavioral review/authorization processes to ensure coverage within benefit and medical necessity guidelines.
• Make referrals to appropriate staff (Medical Director, Case Manager, etc.) and participate in data collection for clinical information flow.
• Ensure compliance with regulatory requirements including ERISA, NCQA, URAC, DOI, and DOL.
• Provide discharge planning, assess service needs, and evaluate outcomes of care plans.
• Communicate regarding requested services with healthcare providers and members via written and telephone communications.
• Participate in patient education, promote enrollment in care management programs, and conduct on-site reviews when applicable.
• Maintain current knowledge of contracts and network status, assist with claims processing, and resolve issues as needed.

• 4+ years clinical RN experience 
• Ability to process authorization requests in a timely manner
• Effective communication skills with team members, providers, and members
• Knowledge of Medicare criteria and utilization management
• Familiarity with relevant regulatory compliance (ERISA, NCQA, URAC, etc.)
• Knowledge of claims and coding analysis
• Ability to work independently, prioritize, and make sound decisions
• Demonstrated customer service and organizational skills
• Proficiency in Microsoft Office, especially Word
• Strong judgment skills and discretion handling sensitive information
• Analytical and critical thinking abilities

• Utilization management and/or Appeals experience
• Behavioral health or infusion therapy experience
• Previous Medicare and UR experience
• Knowledge of claims and coding processes
• Proficiency in Microsoft Excel, Access, or similar tools
• Case management or clinical certification in relevant specialties (e.g., nursing, social work, counseling)

If you meet the requirements and are ready to contribute to a dynamic healthcare team, apply now. This opportunity offers the chance to work in a supportive environment with growth potential.

As a trusted technology partner, CEI delivers solutions that help our customers transform their business and achieve meaningful results. From strategy and custom application development through application management - our technology and digital experience services are tailored to meet each unique need of our customers. Our staffing solutions bring specialized skills to complement our customers' workforce and project requirements.

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