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Job DescriptionMust live within 2 hours of Columbia, SC Must be able to work the first 1-2 weeks on site in Columbia, then would be fully remote Must have an active RN License in the state of SC Overview This role involves reviewing and evaluating medical or behavioral eligibility regarding benefits and clinical criteria, applying clinical expertise and policies to service requests. The position supports members in managing their health through health coaching, care coordination, and monitoring, utilizing clinical proficiency and claims knowledge to promote quality, cost-effective outcomes. Key Responsibilities • Perform medical or behavioral review/authorization processes, ensuring coverage within benefit and medical necessity guidelines., • Assess service needs, develop and coordinate action plans with members, and monitor services., • Evaluate outcomes, eligibility, benefits, and medical necessity of requested services., • Initiate or coordinate discharge planning or alternative treatment plans as needed., • Document clinical information accurately to support medical necessity and contract benefits., • Utilize resources to support review determinations and make referrals to appropriate staff., • Participate in data collection for clinical information flow and claims adjudication., • Engage in direct intervention and patient education regarding healthcare delivery, utilization, and benefit plans., • Support members with chronic conditions or at-risk populations through telephonic coaching and motivational interviewing., • Maintain current knowledge of contracts and network status, assisting with claims discussions and resolutions., • Communicate effectively with healthcare providers and members regarding services requested.Required Skills, • Minimum of 2 years clincial RN experience, • Working knowledge of word processing software., • Ability to work independently, prioritize, and make sound decisions., • Strong judgment, organizational, and presentation skills., • Excellent spelling, punctuation, grammar, and communication skills., • Ability to persuade, negotiate, and influence others., • Strong analytical and critical thinking skills., • Discretion in handling confidential or sensitive information., • Proficiency with Microsoft Office.Preferred Skills, • Working knowledge of spreadsheet and database software., • Knowledge of contract language and its application., • Understanding of claims/coding analysis, requirements, and processes. #ZR #INDGEN