This is a fully remote position, open to applicants in Georgia.

📋 Description

• Evaluate, plan, implement, coordinate, monitor, and assess options to ensure suitable healthcare services and benefits for members.

• Collect clinical information and apply relevant clinical criteria, guidelines, policies, procedures, and clinical judgment to make coverage decisions or recommendations.

• Engage with providers and other stakeholders to facilitate care and treatment.

• Identify members for referral opportunities by integrating various products, services, and programs.

• Recognize opportunities to enhance the quality and efficiency of healthcare services and benefit usage.

• Provide consultation and expertise to both internal and external parties in the coordination and management of utilization and benefits.

• Operate within a 24/7 utilization management environment, including availability during holidays and evening hours.

⛳️ Requirements

• Minimum of 3 years of experience as a Registered Nurse.

• Must possess an active, current, and unrestricted RN license in the state of residence.

• At least 1 year of Med/Surg experience.

• A minimum of 1 year of experience with Microsoft Office applications (Outlook, Teams, Excel).

• Must be willing and able to work 10-hour shifts on Saturday, Sunday, Monday, and Tuesday after approximately 4–5 months of training, which runs Monday–Friday from 7:30 am to 6 pm EST, including occasional holiday rotations.

• Experience with Medicare is essential.

• An Associate's degree is required.

• Prior Authorization or Utilization Management experience is preferred.

• Experience in managed care is preferred.

• Familiarity with MedCompass is preferred.

• Ambulatory surgery experience is preferred.

• A BSN is preferred.