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

📋 Description

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

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

• Communicate with healthcare providers and other stakeholders to support care and treatment.

• Identify members for referral opportunities related to various products, services, and programs.

• Recognize opportunities to enhance the quality of healthcare services and efficient benefit utilization.

• Consult with and offer expertise to both internal and external parties in managing utilization and administering benefits.

⛳️ Requirements

• A minimum of 3 years of experience as a Registered Nurse.

• 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).

• Willingness and capability to work 10-hour shifts on Saturday, Sunday, Monday, and Tuesday after approximately 4–5 months of training from Monday to Friday, 7:30 am–6 pm EST, including occasional holiday rotation.

• An associate degree is required.

• Prior Authorization or Utilization Management experience is preferred.

• Managed care experience is preferred.

• Experience using MedCompass is preferred.

• Ambulatory surgery experience is preferred.

• Medicare experience is required.

• A BSN is preferred.