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 data and apply clinical standards, guidelines, policies, procedures, and clinical judgment to make coverage decisions or suggestions.

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

• Recognize members for referral opportunities involving alternative products, services, and programs.

• Discover opportunities to enhance the quality of healthcare services and effective benefit utilization.

• Consult and provide expertise to both internal and external parties in managing and coordinating utilization and benefit management.

• Take part in a 24/7 utilization management operation, including working during holidays and evening hours.

⛳️ Requirements

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

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

• Prior Authorization or Utilization Management experience is preferred.

• Managed care experience is preferred.

• Familiarity with MedCompass is preferred.

• Ambulatory surgery experience is preferred.

• Medicare experience is required.

• An Associate's degree is required.

• A BSN is preferred.